The core Gestalt of schizophrenia

Schizophrenia, the very idea: On self-disorder, hyperreflexivity, and the diagnostic concept

The purpose of the present article is to consider schizophrenia-the very idea-from the perspective of phenomenological psychopathology, with special attention to the problematic nature of the diagnostic concept as well as to the prospect and challenges inherent in focusing on subjective experience. First, we address historical and philosophical topics relevant to the legitimacy of diagnostic categorization-in general and regarding "schizophrenia" in particular. William James's pragmatist approach to categorization is discussed. Then we offer a version of the well-known basic-self or ipseity-disturbance model (IDM) of schizophrenia, but in a significantly revised form (IDMrevised). The revised model better acknowledges the diverse and even seemingly contradictory nature of schizophrenic symptoms while, at the same time, interpreting these in a more unitary fashion via the key concept of hyperreflexivity-a form of exaggerated self-awareness that tends to undermine normal world-directedness and the stability of self-experience. Particular attention is paid to forms of exaggerated "self-presence" that are sometimes neglected yet imbue classically schizophrenic experiences involving subjectivism or quasi-solipsism and/or all-inclusive or ontological forms of paranoia. We focus on the distinctively paradoxical nature of schizophrenic symptomatology. In concluding we consider precursors in the work of Klaus Conrad, Kimura Bin and Henri Grivois. Finally we defend the concept of schizophrenia by considering its distinctive way of altering certain core aspects of the human condition itself.

Self-Disorder in Schizophrenia: A Revised View (1. Comprehensive Review-Dualities of Self- and World-Experience)

A growing body of research supports the role of self-disorders as core phenotypic features of schizophrenia-spectrum disorders. Self-disorders comprise various alterations of conscious experience whose theoretical understanding continues to present a challenge. The following 2 articles aim to provide further clarification of the nature of self-disorders in schizophrenia by offering a comprehensive review (article 1) and theoretical revision (article 2) of the currently most influential model of altered selfhood in schizophrenia: the basic-self-disturbance or ipseity-disorder model (IDM). This article presents a state-of-the-art overview of the current self-disturbance model and critically assesses its descriptive adequacy with respect to the clinical variability and heterogeneity of the alterations in self- and world-awareness characteristic of schizophrenia. Special attention is paid to experiences of exaggerated basic self, increased "grip" or "hold" on the world, and paradoxical combinations. The next article proposes a theoretical revision of the self-disturbance model by considering how hyperreflexivity might form the crucial common thread or generating factor that unifies the phenomenologically heterogeneous, and sometimes even contradictory features of schizophrenic self-disorders. We outline the implications of our revised model for explanatory research, therapeutic practice, and our general understanding of the abnormalities in question.

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.

As without, so within: how the brain's temporo-spatial alignment to the environment shapes consciousness

Consciousness is constituted by a structure that includes contents as foreground and the environment as background. This structural relation between the experiential foreground and background presupposes a relationship between the brain and the environment, often neglected in theories of consciousness. The temporo-spatial theory of consciousness addresses the brain-environment relation by a concept labelled 'temporo-spatial alignment'. Briefly, temporo-spatial alignment refers to the brain's neuronal activity's interaction with and adaption to interoceptive bodily and exteroceptive environmental stimuli, including their symmetry as key for consciousness. Combining theory and empirical data, this article attempts to demonstrate the yet unclear neuro-phenomenal mechanisms of temporo-spatial alignment. First, we suggest three neuronal layers of the brain's temporo-spatial alignment to the environment. These neuronal layers span across a continuum from longer to shorter timescales. (i) The background layer comprises longer and more powerful timescales mediating topographic-dynamic similarities between different subjects' brains. (ii) The intermediate layer includes a mixture of medium-scaled timescales allowing for stochastic matching between environmental inputs and neuronal activity through the brain's intrinsic neuronal timescales and temporal receptive windows. (iii) The foreground layer comprises shorter and less powerful timescales for neuronal entrainment of stimuli temporal onset through neuronal phase shifting and resetting. Second, we elaborate on how the three neuronal layers of temporo-spatial alignment correspond to their respective phenomenal layers of consciousness. (i) The inter-subjectively shared contextual background of consciousness. (ii) An intermediate layer that mediates the relationship between different contents of consciousness. (iii) A foreground layer that includes specific fast-changing contents of consciousness. Overall, temporo-spatial alignment may provide a mechanism whose different neuronal layers modulate corresponding phenomenal layers of consciousness. Temporo-spatial alignment can provide a bridging principle for linking physical-energetic (free energy), dynamic (symmetry), neuronal (three layers of distinct time-space scales) and phenomenal (form featured by background-intermediate-foreground) mechanisms of consciousness.

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.

Abnormal global signal topography of self modulates emotion dysregulation in major depressive disorder

Major depressive disorder (MDD) is a complex mental disorder featured by an increased focus on the self and emotion dysregulation whose interaction remains unclear, though. At the same time, various studies observed abnormal representation of global fMRI brain activity in specifically those regions, e.g., cortical midline structure (CMS) in MDD that are associated with the self. Are the self and its impact on emotion regulation related to global brain activity unevenly represented in CMS relative to non-CMS? Addressing this yet open question is the main goal of our study. We here investigate post-acute treatment responder MDD and healthy controls in fMRI during an emotion task involving both attention and reappraisal of negative and neutral stimuli. We first demonstrate abnormal emotion regulation with increased negative emotion severity on the behavioral level. Next, focusing on a recently established three-layer topography of self, we show increased representation of global fMRI brain activity in specifically those regions mediating the mental (CMS) and exteroceptive (Right temporo-parietal junction and mPFC) self in post-acute MDD during the emotion task. Applying a complex statistical model, namely multinomial regression analyses, we show that increased global infra-slow neural activity in the regions of the mental and exteroceptive self modulates the behavioral measures of specifically negative emotion regulation (emotion attention and reappraisal/suppression). Together, we demonstrate increased representation of global brain activity in regions of the mental and exteroceptive self, including their modulation of negative emotion dysregulation in specifically the infra-slow frequency range (0.01 to 0.1 Hz) of post-acute MDD. These findings support the assumption that the global infra-slow neural basis of the increased self-focus in MDD may take on the role as basic disturbance in that it generates the abnormal regulation of negative emotions.

Does method matter? Assessing the validity and clinical utility of structured diagnostic interviews among a clinical sample of first-admitted patients with psychosis: A replication study

Introduction

Increasingly, diagnostic assessments in clinical practice are made using structured diagnostic interviews or self-rating scales imported into clinical practice from research studies and big-scale surveys. Although structured diagnostic interviews have been shown to be highly reliable in research, the use of such method in clinical contexts are more questionable. In fact the validity and clinical utility of such methods in naturalistic contexts have rarely been evaluated. In this study we report on a replication study of Nordgaard et al (22) Assessing the diagnostic validity of a structured psychiatric interview in a first-admission hospital sample. World Psychiatry, 11 (3): 181-185.

Methods

The study sample comprises 55 first-admitted inpatients to a treatment facility specializing in the assessment and treatment of patients with psychotic disorders.

Results

We found poor agreement between diagnoses generated by Structured Clinical Interview for DSM-IV and Best-estimate consensus diagnoses (κ value 0.21).

Discussion

We identified over-reliance on self-report, vulnerability to response set in dissimulating patients, and a strong diagnosis and comorbidity focus, as possible reasons for misdiagnosis with the SCID. We conclude that structured diagnostic interviews performed by mental health professionals without solid psychopathological knowledge and experience are not recommendable for clinical practice.

Decreased cortical gyrification and surface area in the left medial parietal cortex in patients with treatment-resistant and ultratreatment-resistant schizophrenia

AIM

Validating the vulnerabilities and pathologies underlying treatment-resistant schizophrenia (TRS) is an important challenge in optimizing treatment. Gyrification and surface area (SA), reflecting neurodevelopmental features, have been linked to genetic vulnerability to schizophrenia. The aim of this study was to identify gyrification and SA abnormalities specific to TRS.

METHODS

We analyzed 3T magnetic resonance imaging findings of 24 healthy controls (HCs), 20 responders to first-line antipsychotics (FL-Resp), and 41 patients with TRS, including 19 clozapine responders (CLZ-Resp) and 22 FL- and clozapine-resistant patients (patients with ultratreatment-resistant schizophrenia [URS]). The local gyrification index (LGI) and associated SA were analyzed across groups. Diagnostic accuracy was verified by receiver operating characteristic curve analysis.

RESULTS

Both CLZ-Resp and URS had lower LGI values than HCs (P = 0.041, Hedges g [g_H ] = 0.75; P = 0.013, g_H  = 0.96) and FL-Resp (P = 0.007, g_H  = 1.00; P = 0.002, g_H  = 1.31) in the left medial parietal cortex (Lt-MPC). In addition, both CLZ-Resp and URS had lower SA in the Lt-MPC than FL-Resp (P < 0.001, g_H  = 1.22; P < 0.001, g_H  = 1.75). LGI and SA were positively correlated in non-TRS (FL-Resp) (ρ = 0.64, P = 0.008) and TRS (CLZ-Resp + URS) (ρ = 0.60, P < 0.001). The areas under the receiver operating characteristic curve for non-TRS versus TRS with LGI and SA in the Lt-MPC were 0.79 and 0.85, respectively. SA in the Lt-MPC was inversely correlated with negative symptoms (ρ = -0.40, P = 0.018) and clozapine plasma levels (ρ = -0.35, P = 0.042) in TRS.

CONCLUSION

LGI and SA in the Lt-MPC, a functional hub in the default-mode network, were abnormally reduced in TRS compared with non-TRS. Thus, altered LGI and SA in the Lt-MPC might be structural features associated with genetic vulnerability to TRS.

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.

Spatiotemporal Psychopathology - A Novel Approach to Brain and Symptoms

How can we characterize psychopathological symptoms and connect them to the brain? Current psychopathological symptoms only focus on either the symptoms themselves or predominantly on the brain. This leaves open their intimate connection. A novel approach, Spatiotemporal Psychopathology, proposes that the brain inner spatiotemporal organisation of its neural activity provides the spatiotemporal organization of the psychopathological symptoms. Specifically, the brains' neuronal topography and dynamic is manifest in a more or less analogous spatiotemporal organisation on the mental level, i.e., mental topography and dynamic. This is strongly supported by various examples including major depressive disorder, bipolar disorder, schizophrenia, and autism. We therefore conclude that Spatiotemporal Psychopathology provides a promising approach to intimately connect brain and symptoms.

Beyond noise to function: reframing the global brain activity and its dynamic topography

How global and local activity interact with each other is a common question in complex systems like climate and economy. Analogously, the brain too displays 'global' activity that interacts with local-regional activity and modulates behavior. The brain's global activity, investigated as global signal in fMRI, so far, has mainly been conceived as non-neuronal noise. We here review the findings from healthy and clinical populations to demonstrate the neural basis and functions of global signal to brain and behavior. We show that global signal (i) is closely coupled with physiological signals and modulates the arousal level; and (ii) organizes an elaborated dynamic topography and coordinates the different forms of cognition. We also postulate a Dual-Layer Model including both background and surface layers. Together, the latest evidence strongly suggests the need to go beyond the view of global signal as noise by embracing a dual-layer model with background and surface layer.

Inner Conflict of Personality in the Paradigm of Existential-Phenomenological Ontology

This article analyzes the problem of internal personality conflicts from the the standpoint of existential-phenomenological ontology. The article presents a theoretical substantiation of phenomenological ontology as a nonclassical paradigm in the human sciences to solve existential conflicts in personality. It is noted that the main models of internal conflict do not give a satisfactory answer to the question of psychogenesis and psychological mechanisms for resolving existential conflicts. It is emphasized that it is perspective to analyze internal conflicts, relying upon phenomenological ontology and the existential approach. The main provisions of phenomenological ontology presented in the works of Husserl and Heidegger, as the founders of this scientific direction, are considered in a psychological context. A classification of existential experiences of a difficult life world is proposed, depending on the intra- and inter-orientation of mental processes. The concepts of the self-closing life world, ambivalent Other, ambivalent intentionality, spontaneous involvement are introduced, making it possible to substantiate a conceptual model for resolving existential personality conflicts. It is concluded that the resolution of existential conflicts is associated with the feeling of an intersubjective life-world, in which the ambivalent Other and spontaneous bodily involvement play a primary role.

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.

Time in schizophrenia: a link between psychopathology, psychophysics and technology

It has been widely demonstrated that time processing is altered in patients with schizophrenia. This perspective review delves into such temporal deficit and highlights its link to low-level sensory alterations, which are often overlooked in rehabilitation protocols for psychosis. However, if temporal impairment at the sensory level is inherent to the disease, new interventions should focus on this dimension. Beyond more traditional types of intervention, here we review the most recent digital technologies for rehabilitation and the most promising ones for sensory training. The overall aim is to synthesise existing literature on time in schizophrenia linking psychopathology, psychophysics, and technology to help future developments.

Augmenting Human Selves Through Artificial Agents – Lessons From the Brain

Much of current artificial intelligence (AI) and the drive toward artificial general intelligence (AGI) focuses on developing machines for functional tasks that humans accomplish. These may be narrowly specified tasks as in AI, or more general tasks as in AGI – but typically these tasks do not target higher-level human cognitive abilities, such as consciousness or morality; these are left to the realm of so-called “strong AI” or “artificial consciousness.” In this paper, we focus on how a machine can augment humans rather than do what they do, and we extend this beyond AGI-style tasks to augmenting peculiarly personal human capacities, such as wellbeing and morality. We base this proposal on associating such capacities with the “self,” which we define as the “environment-agent nexus”; namely, a fine-tuned interaction of brain with environment in all its relevant variables. We consider richly adaptive architectures that have the potential to implement this interaction by taking lessons from the brain. In particular, we suggest conjoining the free energy principle (FEP) with the dynamic temporo-spatial (TSD) view of neuro-mental processes. Our proposed integration of FEP and TSD – in the implementation of artificial agents – offers a novel, expressive, and explainable way for artificial agents to adapt to different environmental contexts. The targeted applications are broad: from adaptive intelligence augmenting agents (IA’s) that assist psychiatric self-regulation to environmental disaster prediction and personal assistants. This reflects the central role of the mind and moral decision-making in most of what we do as humans.

Disturbance of Ecological Self and Impairment of Affordance Perception

Affordance, a radical concept James Gibson introduced in the 1970s, remains controversial today. Defined as environmental properties taken with reference to an animal's anatomy and action capabilities, affordances are opportunities for action the environment offers. By perceiving affordances, organisms hold meaningful relationships with their surroundings. Affordance is not just a theoretical concept but, as the embodiment of meanings and values, has serious psychological implications. We contend that the lack of these meanings and values underlies the irrational behavior seen in patients with self disorders such as schizophrenia. We reason that it is by perceiving affordances that individuals keep in touch with their surroundings and stay mentally healthy. Using contrapositive reasoning, the reverse could also be true. That is, when individuals experience difficulty maintaining meaningful relations with their surroundings and suffer from mental health problems, we might anticipate that their affordance detection systems are impaired. In two studies conducted in our laboratory, patients with schizophrenia and Alzheimer's disease were shown to have impaired capacity to perceive affordances, a result qualifying as contra-positive evidence corroborating the affordance concept. In addition, our results provide support for accepting contra-positive evidence as a complementary tool to positive evidence for empirically validating concepts such as affordance and meaning.

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.

Clusters, lines and webs-so does my patient have psychosis? reflections on the use of psychiatric conceptual frameworks from a clinical vantage point

Mental health professionals working in hospitals or community clinics inevitably face the realisation that we possess imperfect conceptual means to understand mental disorders. In this paper the authors bring together ideas from the fields of Philosophy, Psychiatry, Cognitive Psychology and Linguistics to reflect on the ways we represent phenomena of high practical importance that we often take for granted, but are nevertheless difficult to define in ontological terms. The paper follows through the development of the concept of psychosis over the last two centuries in the interplay of three different conceptual orientations: the categorical, dimensional and network approaches. Each of these represent the available knowledge and dominant thinking styles of the era in which they emerged and take markedly different stances regarding the nature of mental phenomena. Without particular commitment to any ontological positions or models described, the authors invite the reader into a thinking process about the strengths and weaknesses of these models, and how they can be reconciled in multidisciplinary settings to benefit the process of patient care.

Body structural representation in schizotypy

A deficient sense of self, typically observed in schizophrenia spectrum disorders, is often accompanied by abnormalities in bodily perception and awareness. These abnormalities are seemingly among the most powerful predictive factors for the onset of schizophrenic illnesses. According to the hypothesis of the psychosis continuum, high schizotypal traits in the general population may be characterized by a progressive sense of detachment from one's lived body. Building upon previous research that found an abnormal Body Structural Representation (BSR) in individuals with schizophrenia, this study aims to extend these findings to schizotypy. To investigate this, we utilized the Finger Localization Task (FLT), in which participants must identify the finger touched by the experimenter, and the In Between Task (IBT), in which two fingers are touched and participants must specify the number of fingers in between the two stimulated fingers. We found that individuals with high schizotypy were significantly less accurate than individuals with low schizotypy in determining the spatial configuration of their own fingers relative to each other. Most significantly, performances on both tasks were negatively correlated with the score on the Dissociative Experiences Scale (DES). These findings support the hypothesis that the progressive loss of one's sense of self is associated with abnormal bodily experiences and dissociative symptomatology which may represent a potential marker for schizophrenia proneness.

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.

Integrating trauma, self-disturbances, cognitive biases, and personality into a model for the risk of psychosis: a longitudinal study in a non-clinical sample

The hypothesis of the psychosis continuum enables to study the mechanisms of psychosis risk not only in clinical samples but in non-clinical as well. The aim of this longitudinal study was to investigate self-disturbances (SD), a risk factor that has attracted substantial interest over the last two decades, in combination with trauma, cognitive biases and personality, and to test whether SD are associated with subclinical positive symptoms (PS) over a 12-month follow-up period. Our study was conducted in a non-clinical sample of 139 Polish young adults (81 females, age M = 25.32, SD = 4.51) who were selected for frequent experience of subclinical PS. Participants completed self-report questionnaires for the evaluation of SD (IPASE), trauma (CECA.Q), cognitive biases (DACOBS) and personality (TCI), and were interviewed for subclinical PS (CAARMS). SD and subclinical PS were re-assessed 12 months after baseline measurement. The hypothesized model for psychosis risk was tested using path analysis. The change in SD and subclinical PS over the 12-month period was investigated with non-parametric equivalent of dependent sample t-tests. The models with self-transcendence (ST) and harm avoidance (HA) as personality variables were found to be well-fitted and explained 34% of the variance in subclinical PS at follow-up. Moreover, we found a significant reduction of SD and subclinical PS after 12 months. Our study suggests that combining trauma, cognitive biases, SD and personality traits such as ST and HA into one model can enhance our understanding of appearance as well as maintenance of subclinical PS.

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.

Schizophrenia spectrum disorders in children and adolescents: prevalence and diagnostics

The significance of studying the prevalence, age- and sex-related differences and diagnostic aspects of schizophrenia spectrum disorders (F2 Schizophrenia, schizotypal and delusional disorders) in pediatric and adolescent patients of mental health facilities is linked to the upcoming release of the International Classification of Diseases, Revision 11 (ICD-11). Its whole chapters have been updated, including disorders in the schizophrenia group. Diagnostic challenges posed by this debilitating group of mental disorders are associated with the diversity of clinical presentations, the incompleteness of psychopathological phenomena syndromes, and vague atypical symptoms. Changes in the prevalence of these disorders identified by the analysis of medical records at a mental health facility for children (a decline in the number of patients with F20, schizophrenia, and a surge in the number of patients with F21, schizotypal disorder) and significant disagreement about and disagreement about the diagnostic criteria for schizophrenia spectrum disorders in children and adolescents, evaluation of their dynamics, outcomes, and the social functioning of the patient necessitate further prospective follow-up studies aimed at overcoming the identified difficulties in the diagnosis, treatment and rehabilitation of such patients.

The clinical characterization of the patient with primary psychosis aimed at personalization of management

The current management of patients with primary psychosis worldwide is often remarkably stereotyped. In almost all cases an antipsychotic medica-tion is prescribed, with second-generation antipsychotics usually preferred to first-generation ones. Cognitive behavioral therapy is rarely used in the vast majority of countries, although there is evidence to support its efficacy. Psychosocial interventions are often provided, especially in chronic cases, but those applied are frequently not validated by research. Evidence-based family interventions and supported employment programs are seldom implemented in ordinary practice. Although the notion that patients with primary psychosis are at increased risk for cardiovascular diseases and diabetes mellitus is widely shared, it is not frequent that appropriate measures be implemented to address this problem. The view that the management of the patient with primary psychosis should be personalized is endorsed by the vast majority of clinicians, but this personalization is lacking or inadequate in most clinical contexts. Although many mental health services would declare themselves "recovery-oriented", it is not common that a focus on empowerment, identity, meaning and resilience is ensured in ordinary practice. The present paper aims to address this situation. It describes systematically the salient domains that should be considered in the characterization of the individual patient with primary psychosis aimed at personalization of management. These include positive and negative symptom dimensions, other psychopathological components, onset and course, neurocognition and social cognition, neurodevelopmental indicators; social functioning, quality of life and unmet needs; clinical staging, antecedent and concomitant psychiatric conditions, physical comorbidities, family history, history of obstetric complications, early and recent environmental exposures, protective factors and resilience, and internalized stigma. For each domain, simple assessment instruments are identified that could be considered for use in clinical practice and included in standardized decision tools. A management of primary psychosis is encouraged which takes into account all the available treatment modalities whose efficacy is supported by research evidence, selects and modulates them in the individual patient on the basis of the clinical characterization, addresses the patient's needs in terms of employment, housing, self-care, social relationships and education, and offers a focus on identity, meaning and resilience.

Subjective experience of social cognition in young people at Ultra-High Risk of psychosis: a 2-year longitudinal study

Impairments in SC have been reported in people at Ultra-High Risk (UHR) of psychosis exclusively using neurocognitive tasks. The aims of this study are (1) to assess subjective experience of SC in adolescent and young adult community help-seekers identified through UHR criteria, (2) to explore significant associations of SC with psychopathology and functioning in UHR individuals; and (3) to monitor longitudinally the SC stability after a 2-year follow-up period. Methods: Participants (97 UHR, 141 First-Episode Psychosis [FEP], and 98 non-UHR/FEP), aged 13-35 years, completed the Comprehensive Assessment of At-Risk Mental States (CAARMS) and the GEOPTE scale of social cognition for psychosis. Within the UHR group, a multiple linear regression analysis (with GEOPTE scores as independent variables and CAARMS dimension subscores and treatment measures as dependent variables) was also performed across the 2-year longitudinal design. Results: In comparison with non-UHR/FEP, both UHR and FEP subjects showed significantly higher GEOPTE scores. Both after 12 and 24 months of follow-up, UHR individuals had a significant decrease in severity on GEOPTE SC subscore. In the UHR group, GEOPTE scores showed significant positive correlations with general psychopathology, positive and negative symptoms. Regression analysis showed a significant contribution of SC in predicting baseline social isolation, impaired role functioning, and general psychopathology. After 1 year of follow-up, improvement in SC was predicted by the number of psychotherapy sessions and lower doses of antipsychotics. Conclusions: SC deficits are prominent in UHR individuals and are similar in severity to those of FEP patients. However, they tend to decrease over time along with the delivery of targeted, specialized interventions for early psychosis.

Neural Correlates of Self-other Distinction in Patients with Schizophrenia Spectrum Disorders: The Roles of Agency and Hand Identity

Schizophrenia spectrum disorders (SSD) are characterized by disturbed self-other distinction. While previous studies associate abnormalities in the sense of agency (ie, the feeling that an action and the resulting sensory consequences are produced by oneself) with disturbed processing in the angular gyrus, passive movement conditions to isolate contributions of motor predictions are lacking. Furthermore, the role of body identity (ie, visual features determining whether a seen body part belongs to oneself) in self-other distinction is unclear. In the current study, fMRI was used to assess the roles of agency and hand identity in self-other distinction. Patients with SSD and healthy controls (HC) performed active and passive hand movements (agency manipulation) while seeing their own or someone else's hand moving in accordance with their action (hand identity manipulation). Variable delays (0-417 ms) between movement and feedback had to be detected. Our results showed overall lower delay detection performances during active than passive conditions; however, these differences were reduced in patients when the own hand was displayed. On a neural level, we found that in HC, activation in the right angular gyrus was modulated by agency and hand identity. In contrast, agency and hand identity revealed no overlapping activation in patients, due to reduced effects of agency. Importantly, HC and SSD patients shared similar effects of hand identity in the angular gyrus. Our results suggest that disturbances of self-other distinction in SSD are particularly driven by agency, while self-other distinction based on hand identity might be spared.

Autism Rating Scale: A New Tool for Characterizing the Schizophrenia Phenotype

Social dysfunctions (SD) are frequently observed in subjects with schizophrenia. Some of these dysfunctions are also observed in other neuropsychiatric disorders such as autism spectrum disorders (ASD), major depression, bipolar disorder, or Alzheimer disease. Recently, a characterization of a specific type of SD in schizophrenia has been proposed, with the concept of dis-sociality, which form the core aspect of "Schizophrenic Autism" (SA). The present study aimed to explore the presence in people with schizophrenia of SA, independent of other autistic traits, which can be often found in schizophrenia and other neurodevelopmental disorders. We used a structured interview-the Autism Rating Scale (ARS), an instrument devised to detect and measure SA. Fifty-one outpatients affected by schizophrenia (26 remitted, SCZ-r) and 28 affected by bipolar disorder type 1, with psychotic features, in the euthymic phase (BD-e) were recruited. Before assessing the specificity for schizophrenia of SA, we tested the internal consistency, the convergent and divergent validity of the ARS in the schizophrenia sample. Specificity was assessed by examining potential differences in ARS scores between SCZ-r and BD-e subjects. ARS showed good internal consistency, as well as convergent and divergent validity. ARS items were more frequently of moderate severity in SCZ-r than in BD-e subjects. This scale can contribute to establish more precise phenomenal boundaries between schizophrenia and bipolar disorder, and opens up the possibility of identifying a different type of SD in schizophrenia, independent of autistic traits and negative symptoms, which might benefit from different treatments.

Psychotic-Like Experiences: A Challenge in Definition and Assessment

Assuming a continuum between psychotic experiences and psychotic symptoms aligned between healthy individuals and patients with non-psychotic and psychotic disorders, recent research has focused on subclinical psychotic experiences. The wide variety of definitions, assessment tools, and concepts of psychotic-like experiences (PLEs) might contribute to the mixed findings concerning prevalence and persistence rates and clinical impact. In this narrative review, we address the panoply of terminology, definitions, and assessment tools of PLEs and associated concerns with this multitude. Moreover, the ambiguous results of previous studies regarding the clinical relevance of PLEs are described. In conclusion, we address clinical implications and highly suggest conceptual clarity and consensus concerning the terminology and definition of PLEs. The development of an agreed upon use of a "gold standard" assessment tool seems essential for more comparable findings in future research.

When the World Breaks Down: A 3-Stage Existential Model of Nihilism in Schizophrenia

The existential crisis of nihilism in schizophrenia has been reported since the early days of psychiatry. Taking first-person accounts concerning nihilistic experiences of both the self and the world as vantage point, we aim to develop a dynamic existential model of the pathological development of existential nihilism. Since the phenomenology of such a crisis is intrinsically subjective, we especially take the immediate and pre-reflective first-person perspective's (FPP) experience (instead of objectified symptoms and diagnoses) of schizophrenia into consideration. The hereby developed existential model consists of 3 conceptualized stages that are nested into each other, which defines what we mean by existential. At the same time, the model intrinsically converges with the phenomenological concept of the self-world structure notable inside our existential framework. Regarding the 3 individual stages, we suggest that the onset or first stage of nihilistic pathogenesis is reflected by phenomenological solipsism, that is, a general disruption of the FPP experience. Paradigmatically, this initial disruption contains the well-known crisis of common sense in schizophrenia. The following second stage of epistemological solipsism negatively affects all possible perspectives of experience, that is, the first-, second-, and third-person perspectives of subjectivity. Therefore, within the second stage, solipsism expands from a disruption of immediate and pre-reflective experience (first stage) to a disruption of reflective experience and principal knowledge (second stage), as mirrored in abnormal epistemological limitations of principal knowledge. Finally, the experience of the annihilation of healthy self-consciousness into the ultimate collapse of the individual's existence defines the third stage. The schizophrenic individual consequently loses her/his vital experience since the intentional structure of consciousness including any sense of reality breaks down. Such a descriptive-interpretative existential model of nihilism in schizophrenia may ultimately serve as input for future psychopathological investigations of nihilism in general, including, for instance, its manifestation in depression.

Subjective experience of social cognition in adolescents at ultra-high risk of psychosis: findings from a 24-month follow-up study

Deficits in social cognition have been reported in people at ultra-high risk (UHR) of psychosis exclusively using socio-cognitive tasks and in adolescent and young adult mixed population. Aim of this study was (1) to assess subjective experience of social cognition in adolescent help-seekers identified through UHR criteria, (2) to explore its significant correlations with psychopathology and functioning in UHR individuals; and (3) to monitor longitudinally its stability after a 24-month follow-up period. Participants [51 UHR, 91 first-episode psychosis (FEP), and 48 non-UHR/FEP patients], aged 13-18 years, completed the comprehensive assessment of at-risk mental states and the GEOPTE scale of social cognition for psychosis. In comparison with non-UHR/FEP patients, both UHR and FEP adolescents showed significantly higher GEOPTE total scores. After 12 months of follow-up, UHR individuals had a significant decrease in severity on GEOPTE "Social Cognition" subscore. In the UHR group at baseline, GEOPTE scores had significant positive correlations with general psychopathology, positive and negative dimensions. Across the 2-year follow-up period, social cognition subscores specifically showed more stable associations with general psychopathology and negative symptoms. Social cognition deficits are prominent in UHR adolescents and similar in severity to those of FEP patients at baseline. However, these impairments decreased over time, presumably together with delivery of targeted, specialized models for early intervention in psychosis.

The Self and Its Prolonged Intrinsic Neural Timescale in Schizophrenia

Schizophrenia (SCZ) can be characterized as a basic self-disorder that is featured by abnormal temporal integration on phenomenological (experience) and psychological (information processing) levels. Temporal integration on the neuronal level can be measured by the brain's intrinsic neural timescale using the autocorrelation window (ACW) and power-law exponent (PLE). Our goal was to relate intrinsic neural timescales (ACW, PLE), as a proxy of temporal integration on the neuronal level, to temporal integration related to self-disorder on psychological (Enfacement illusion task in electroencephalography) and phenomenological (Examination of Anomalous Self-Experience [EASE]) levels. SCZ participants exhibited prolonged ACW and higher PLE during the self-referential task (Enfacement illusion), but not during the non-self-referential task (auditory oddball). The degree of ACW/PLE change during task relative to rest was significantly reduced in self-referential task in SCZ. A moderation model showed that low and high ACW/PLE exerted differential impact on the relationship of self-disorder (EASE) and negative symptoms (PANSS). In sum, we demonstrate abnormal prolongation in intrinsic neural timescale during self-reference in SCZ including its relation to basic self-disorder and negative symptoms. Our results point to abnormal relation of self and temporal integration at the core of SCZ constituting a "common currency" of neuronal, psychological, and phenomenological levels.

Defense mechanisms in adolescents at high risk of developing psychosis: an empirical investigation

Research within psychotherapy and psychopathology frameworks has been inspired by the central concept of defense mechanisms, which play a pivotal role in psychoanalysis. Defense specificities have only recently been studied systematically in the context of several clinical diagnoses. The present study aimed to explore the specificities of defense mechanisms in adolescents at ultra-high risk of developing psychosis and test the relationship between defensive functioning and attenuated psychotic symptoms. Twenty-six adolescent inpatients at ultra-high risk of developing psychosis and a matched clinical control group of inpatients not at risk of psychosis were interviewed. Two observer-rater methods, the Defense Mechanism Rating Scales and the Psychotic-Defense Mechanism Rating Scales were applied to interview transcripts to assess the individual use of defenses. Ultra-high-risk patients demonstrated lower defense mechanisms (i.e., total instances of defense mechanisms observed) and lower overall adaptiveness of the defenses presented. When specific differences between groups were observed, psychotic defenses were the sole defenses that could partially discriminate between ultra-high-risk and not at-risk patients. Regarding the relationship between defense mechanisms and subthreshold psychotic symptoms, psychotic defenses were associated with negative and disorganization symptoms, rather than with positive symptoms. The psychological vulnerability of ultra-high-risk patients is discussed and treatment implications for psychotherapy with such challenging patients are addressed.

Abnormal bodily experiences detected by Abnormal Bodily Phenomena questionnaire are more frequent and severe in schizophrenia than in bipolar disorder with psychotic features

BACKGROUND

Patients with schizophrenia display experiential anomalies in their feelings and cognitions arising in the domain of their lived body. These abnormal bodily phenomena (ABP) are not part of diagnostic criteria for schizophrenia. One of the reasons is the difficulty to assess specific ABP for schizophrenia spectrum disorders. The present study aimed to explore the presence in patients with schizophrenia of specific ABP.

METHODS

We used a semistructured interview-the Abnormal Bodily Phenomena questionnaire (ABPq), an instrument devised to detect and measure ABP specific to patients with schizophrenia. Fifty-one outpatients affected by schizophrenia and 28 euthymic outpatients affected by bipolar disorder type I with psychotic features (BD-pf-e) were recruited. Before assessing the specificity for schizophrenia of the observed ABP, we tested the internal consistency and the convergent validity of the ABPq in patients with schizophrenia. Specificity was assessed by examining potential differences in ABPq among the patients with schizophrenia in remission (SCZ-r) and BD-pf-e.

RESULTS

The ABPq shows strong internal consistency and convergent validity. As to the specificity, ABP measured by ABPq were more frequent and severe in SCZ-r than in BD-pf-e. In particular, all ABPq dimensions, except "Coherence," had at least mild severity in over 50% of SCZ-r, while dimensions with at least mild severity were observed in 5-10% of the BD-pf-e.

CONCLUSIONS

These findings can contribute to establish more precise phenomenal boundaries between schizophrenia and bipolar disorder, to explore the borders between nonpsychotic and psychotic forms of ABP, between ABP and negative and disorganized symptoms, and to enlighten core aspects of schizophrenia.

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.

Auditory Verbal Hallucinations in Psychosis: Abnormal Perceptions or Symptoms of Disordered Thought?

Auditory verbal hallucinations (AVHs) are considered as hallmark symptoms of psychosis, more specifically of schizophrenia. A substantial body of evidence indicates that AVHs can be attributed to a disorganization of overall speech capacity in psychotic subjects. AVHs are associated with activation of cortical areas of the brain that are related to speech production and perception; "voices" in deaf patients seem to be about the message rather than the sound of it; the content of AVHs is often related to that of delusional ideas; the internal or external location of AVHs makes little diagnostic difference; AVHs are often related to the patient's subvocal speech, having identical content with that, and they have been theorized as a misattribution of inner speech (i.e., the patient's own thoughts) to external sources. The aforementioned evidence comes close to certain long-standing insights mainly of the French psychiatric (de Clérambault) and psychoanalytical (Lacan) school, according to which, 1) the outside world is perceived through normal language function, 2) a language disorder is central to schizophrenic phenomena, and 3) AVHs represent a fragmentation and autonomization of speech (thought) function in schizophrenic patients (de Clérambault: "hallucinations think"). Today, several authors agree that 1) operationalized definitions have led to an oversimplification of psychopathology, and 2) a more theoretically informed understanding and an integration of different levels of explanation of psychotic phenomena is needed. Thus, psychotic AVHs should be investigated beyond their narrow classification as disordered perceptions, in the wider context of formal thought disorder and disordered language capacity.

Reassessing "Praecox Feeling" in Diagnostic Decision Making in Schizophrenia: A Critical Review

The "Praecox Feeling" (PF) is a classical concept referring to a characteristic feeling of bizarreness experienced by a psychiatrist while encountering a person with schizophrenia. Although the PF used to be considered a core symptom of the schizophrenia spectrum, it fell into disuse since the spread of operationalized diagnostic methods (Diagnostic and Statistical Manual of Mental Disorders/International Classification of Diseases systems). In contemporary research on schizophrenia, it remains largely unaddressed. This critical review investigates the evolution of the PF in historical and contemporary literature and presents an exhaustive overview of empirical evidence on its prevalence in clinical decision making, its reliability and validity. The review demonstrates that the PF is a real determinant of medical decision making in schizophrenia, although, without further research, there is not enough evidence to sustain its rehabilitation as a reliable and valid clinical criterion. PF-like experiences should not be opposed to any criteriological attitude in diagnosis and would be clinically useful if the conditions of descriptive precaution and rigorous epistemology are maintained. The aim of teaching clinical expertise is to transform this basic experience into a well-founded clinical judgment. Finally, the article discusses the possible relevance of the PF for basic science and clinical research according to a translational approach inspired by phenomenology.

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.

A Recurrent Question: What Is Borderline?

The status of borderline personality disorder (BPD) as a diagnostic category is a matter of continuing controversy. In the United States, BPD is one of the most frequent diagnoses of psychiatric inpatients, and a similar tendency emerges in Europe. Nearly all theoretical aspects of BPD have been questioned, including its very position as a personality disorder. In this article, we trace the evolution of the borderline concept from the beginning of the 20th century to the current psychometric research. We argue that the status of BPD is fraught with conceptual difficulties, including an unrecognized semantic drift of major phenomenological terms (e.g., identity), a lack of general principles for the distinction of BPD and the major psychiatric syndromes (e.g., schizophrenia spectrum disorders), and insufficient definitions of key nosological concepts. These difficulties illustrate general problems in today's psychiatry that require consideration.

Temporal Self, Psychopathology, and Adaptive Functioning Deficits: An Examination of Acute Psychiatric Patients

Individuals with psychiatric illness have difficulty remembering specific events from their personal past and imagining their future. We examined psychotic psychiatric inpatients' sense of self-continuity over time, predicting that low levels of temporal continuity would predict increased psychopathology and lower functionality. Inpatients (n = 60) were compared with healthy controls (n = 60) on a validated measure of self-continuity, psychiatric symptoms, insight, and adaptive functioning capacity. Results revealed that patients had significant difficulty perceiving their past, present, and future selves as unified over time compared with controls. Within the inpatient group, deficits in present to future self-continuity was associated with patients' severity of positive, negative, and mood symptoms, degree of insight, and adaptive capacity. It may be the case that temporal self-unity provides a context for deriving reinforcement from daily life experiences in the moment and in anticipating the future as well as a worthwhile goal for treatment exploration.

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.

Schizophrenia and Bipolar Illness in the Relatives of University Scientists: An Epidemiological Report on the Creativity-Psychopathology Relationship

A potential link between creativity and mental illness has been a longstanding topic for human studies and empirical research. The major problem is defining creativity and establishing its measurable indicators. A few high-quality epidemiological studies have been undertaken and point to a link between creativity and vulnerability to mental illness. Demonstrating such a shared vulnerability could expand our understanding of mental illnesses and open up new avenues of empirical research. In this epidemiological study, we defined scientists (academics) at the universities as individuals assumed to exhibit "more creativity" than the background population. In a register coupling with a population of 588,532 people, we examined successful university academics' first- and second-degree relatives for diagnosed mental disorders and compared those figures with controls from the background population controlling for educational level. The relatives of the academics had significantly increased risk of suffering from schizophrenia or bipolar disorder. For bipolar disorder, it is perhaps temperamental features and high energy levels that contribute to this association. In the case of schizophrenia, the mediating bridge may involve an amplification of human tendency to question the obvious and "taken-for-granted." Creativity and an increased risk for mental disorders seem to be linked by a shared vulnerability that is not manifested by clinical mental disorders in the academics.

Identity Disturbance, Feelings of Emptiness, and the Boundaries of the Schizophrenia Spectrum

Historical and current research on borderline personality disorder reveal certain affinities with schizophrenia spectrum psychopathology. This is also the case for the borderline criteria of "identity disturbance" and "feelings of emptiness," which reflect symptomatology frequently found in schizophrenia and schizotypal personality disorder. Unfortunately, the diagnostic manuals offer limited insight into the nature of these criteria, including possible deviations and similarities with schizophrenia spectrum symptomatology. In this article, we attempt to clarify the concepts of identity disturbance and feelings of emptiness with an emphasis on the criteria's differential diagnostic significance. Drawing on contemporary philosophy, we distinguish between a "narrative" self and a "core" self, suggesting that this distinction may assist differential diagnostic efforts and contribute to mark the psychopathological boundaries of these disorders.

The Two Faces of First-Rank Symptoms

Recently, there has been renewed interest in Schneider's first-rank symptoms (FRS) of schizophrenia, thanks in part to a meta-analysis of their diagnostic accuracy, which deserves much credit for its methodological rigor. Conceptualising FRS as a diagnostic test whose performance can be measured in terms of sensitivity and specificity involves some issues that require reflection. First, the full adequacy of sensitivity as a measure of diagnostic accuracy for FRS might be questioned. However, it is conceptually acceptable, though FRS are at a disadvantage as compared with many other psychiatric "diagnostic tests" that should have perfect sensitivity under ideal conditions. Also, from a psychopathological perspective it may well be argued that FRS cannot be conceptualised as a simple, inexpensive diagnostic test suitable for screening purposes; however, the history of the concept reveals some reasons why it may be legitimate to view them this way. While no other relevant study has appeared after the publication of the meta-analysis, data on a further 166 patients from a study that could not be included due to incompletely reported data were located. This brought the total to 4,236 patients from 17 studies on the ability of FRS to differentiate schizophrenia from other psychoses. The resulting summary estimates of sensitivity, specificity and positive and negative likelihood ratios are 60.2%, 75.9%, 2.50, and 0.52, respectively. FRS have a kind of double nature, as they can be legitimately considered as belonging to both a sophisticated framework grounded in phenomenological psychopathology and an eminently pragmatic framework grounded in clinical epidemiology. When FRS are conceptualised as simple clinical indicators that require low levels of inference, the available estimates of their diagnostic accuracy are a fairly valid appraisal of their performance and usefulness, and suggest that FRS have some value in differential diagnosis. However, when FRS are conceptualised as profoundly anomalous experiences that can be properly identified and evaluated only by using a phenomenological approach, these estimates can hardly be seen as a valid evaluation of their diagnostic significance. Phenomenologically informed studies are needed to address this research gap.

Developmental vulnerability to psychosis: Selective aggregation of basic self-disturbance in early onset schizophrenia

Trait-like anomalies of subjective experience (aka, Basic Self-disturbance or Self-disorder, SD) have been empirically identified as schizophrenia-specific markers of vulnerability in several clinical and genetic high-risk populations. However, such specificity is still to be tested in developmental years, where emerging psychopathology is less crystallized and diagnostic boundaries more blurred. Thus, the current study explores the distribution of SD in adolescent help-seekers (age range 14 to 18) and tests the specificity of SD with respect to the severity of their diagnostic staging (Early Onset schizophrenia-spectrum psychosis [EOP], ultra high-risk [UHR] and clinical help-seeking controls [CHSC]). For this purpose, 96 help-seeking adolescents consecutively referred to specialized Child and Adolescent Units for diagnostic evaluation, underwent a comprehensive psychopathological examination including the specific interview for SD (i.e. the Examination of Anomalous Self-Experience, EASE). One-way ANOVA was used to test the diagnostic distribution of SD (EASE score), whereas multinomial logistic regression was used to test the effect of SD on the diagnostic outcome. SD frequency (both in terms of EASE total score and domain sub-scores) was decreasing progressively from EOP to CHSC, with intermediate levels in UHR. The EASE total score increased the risk of belonging to the more severe diagnostic stages (i.e, UHR and EOP vs CHSC as reference class) and allowed the correct reclassification of the 75% of the sample. The results confirm the schizophrenia-spectrum specificity of SD in adolescence, highlighting their potential value for early differential diagnosis and risk stratification.

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

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