Abnormal Space Experiences in Persons With Schizophrenia: An Empirical Qualitative Study

Global neural self-disturbance in schizophrenia: A systematic fMRI review

There is a general consensus that schizophrenia (SZ) is characterized by major changes in the sense of self. Phenomenological studies suggest that these changes in the sense of self stem from a basic disturbance, hence the term 'basic self-disturbance'. While imaging studies demonstrate changes in various regions during self-focused tasks, the exact neural correlates of such basic self-disturbances remain unclear. If the self-disturbance is indeed basic and thereby underlies all other symptoms, one would expect it to be related to more global rather than local changes in the brain. Testing this hypothesis, we conducted a systematic review of fMRI studies on self in SZ. Our main findings are 1. Abnormal activity related to the self can be observed in a variety of different regions ranging from higher-order transmodal to lower-order unimodal regions, 2. These findings hold true across different tasks including self-reflection, self-referentiality, and self-agency, and 3. The global neural abnormalities related to the self in SZ correspond to all layers of the self, predominantly the mental and exteroceptive self. Such global neural disturbance of self converges well with the basic self-disturbance as described in phenomenology.

Arthur Schopenhauer: An underappreciated philosopher in psychiatry and his applied epistemology of body and self- experience

BACKGROUND

Arthur Schopenhauer (1788-1860) was one of the most important thinkers of the 19th century. Although his writings have exerted great influence in many different disciplines, his epistemological concepts and analysis of the body and self-experience were rarely considered in the context of psychiatric research of schizophrenia spectrum disorders (SSD) and depression (MDD).

METHODS

The method applied for the study of anomalous self and body-experience first consists in the close reading and analysis of Schopenhauer's most influential writings, namely his opus magnus "The World as Will and Representation" and his dissertation "On the Fourfold Root of the Principle of Sufficient Reason". Second, psychopathological and phenomenological aspects of the anomalous body and self, as well as altered space and time experience, are discussed by means of Schopenhauer's philosophy and four patient cases.

RESULTS

Schopenhauer's insights contribute to contemporary psychiatry by (1) unifying materialistic (neurobiological) and idealistic (subjective) conceptions of psychiatric disorders and improving the awareness of methods in psychiatric research; (2) emphasizing the integral significance of the body as a gateway to the surrounding world and basal self-experience; (3) delineating subjective space and time-experience as crucial dimensions of the conditio humana in SSD and MDD; and (4) demonstrating the feasibility of transferring his theories directly to clinical case vignettes stemming from the daily clinical routine.

CONCLUSION

Close reading of Schopenhauer's texts might help bridge the gap between different scientific methods in psychiatry and overcome the translational crisis of contemporary psychiatry by unifying neurobiological and subjective approaches to SSD and MDD.

Temporal imprecision of phase coherence in schizophrenia and psychosis-dynamic mechanisms and diagnostic marker

Schizophrenia (SCZ) is a complex disorder in which various pathophysiological models have been postulated. Brain imaging studies using EEG/MEG and fMRI show altered amplitude and, more recently, decrease in phase coherence in response to external stimuli. What are the dynamic mechanisms of such phase incoherence, and can it serve as a differential-diagnostic marker? Addressing this gap in our knowledge, we uniquely combine a review of previous findings, novel empirical data, and computational-dynamic simulation. The main findings are: (i) the review shows decreased phase coherence in SCZ across a variety of different tasks and frequencies, e.g., task- and frequency-unspecific, which is further supported by our own novel data; (ii) our own data demonstrate diagnostic specificity of decreased phase coherence for SCZ as distinguished from major depressive disorder; (iii) simulation data exhibit increased phase offset in SCZ leading to a precision index, in the millisecond range, of the phase coherence relative to the timing of the external stimulus. Together, we demonstrate the key role of temporal imprecision in phase coherence of SCZ, including its mechanisms (phase offsets, precision index) on the basis of which we propose a phase-based temporal imprecision model of psychosis (PTP). The PTP targets a deeper dynamic layer of a basic disturbance. This converges well with other models of psychosis like the basic self-disturbance and time-space experience changes, as discussed in phenomenological and spatiotemporal psychopathology, as well as with the models of aberrant predictive coding and disconnection as in computational psychiatry. Finally, our results show that temporal imprecision as manifest in decreased phase coherence is a promising candidate biomarker for clinical differential diagnosis of SCZ, and more broadly, psychosis.

Spatiotemporal Psychopathology - An integrated brain-mind approach and catatonia

Catatonia is featured by complex symptoms combining motor, affective and behavioral phenomena as well as by its syndrome character with trans-diagnostic occurrence. It paradigmatically shows the limits of current forms of psychopathology like affective and cognitive approaches with respect to both clinical symptoms and brain mechanisms. We therefore suggest Spatiotemporal Psychopathology (STPP) which, as recently introduced, is here developed further following the latest findings in both clinical psychiatry and neuroscience. STPP is characterized by two core features: (i) an experience-based approach that accounts for symptoms primarily in terms of first-person experience of time-space as distinct from third-person observation of specific functions and related behavior; (ii) an integrated brain-mind approach where the brain's neural topography and dynamic, e.g., inner time and space, are shared by the mind's mental topography and dynamic, e.g., time-space experience, as their "common currency". We demonstrate how these two features can well account for both symptom complexity and trans-diagnostic nature of catatonia. In conclusion, catatonia can serve as paradigmatic example for the need to develop a more comprehensive psychopathological approach in psychiatry. This is provided by STPP that allows integrating subjective experience, clinical symptoms and the brain's neural activity in terms of their inner space-time, e.g., topography and dynamic.

Overcoming the translational crisis of contemporary psychiatry - converging phenomenological and spatiotemporal psychopathology

Despite all neurobiological/neurocomputational progress in psychiatric research, recent authors speak about a 'crisis of contemporary psychiatry'. Some argue that we do not yet know the computational mechanisms underlying the psychopathological symptoms ('crisis of mechanism') while others diagnose a neglect of subjectivity, namely first-person experience ('crisis of subjectivity'). In this perspective, we propose that Phenomenological Psychopathology, due to its focus on first-person experience of space and time, is in an ideal position to address the crisis of subjectivity and, if extended to the brain's spatiotemporal topographic-dynamic structure as key focus of Spatiotemporal Psychopathology, the crisis of mechanism. We demonstrate how the first-person experiences of space and time differ between schizophrenia, mood disorders and anxiety disorders allowing for their differential-diagnosis - this addresses the crisis of subjectivity. Presupposing space and time as shared features of brain, experience, and symptoms as their "common currency", the structure of abnormal space and time experience may also serve as template for the structure of the brain's spatiotemporal neuro-computational mechanisms - this may address the crisis of mechanism. Preliminary scientific evidence in our examples of schizophrenia, bipolar disorder, anxiety disorder, and depression support such clinically relevant spatiotemporal determination of both first-person experience (crisis of subjectivity) and the brain's neuro-computational structure (crisis of mechanism). In conclusion, converging Phenomenological Psychopathology with Spatiotemporal Psychopathology might help to overcome the translational crisis in psychiatry by delineating more fine-grained neuro computational and -phenomenal mechanisms; this offers novel candidate biomarkers for diagnosis and therapy including both pharmacological and non-pharmacological treatment.

Logics of Discovery II: Lessons from Poetry-Parataxis as a Method That Can Complement the Narrative Compulsion in Vogue in Contemporary Mental Health Care

This paper highlights the limitations of narrative logic in mental health care, and in particular of "narrative vigilance"-the tendency to watch over experience via narrativisation, and to tether the concrete particulars of experience to the hypothetical structure of a narrative signification. Narrative logic is grounded in hypotaxis-the syntactic structuring whereby a discourse is characterised by different levels of subordination using linking words that connect, especially in terms of temporal and explanatory consequentiality. I offer an alternative approach based on parataxis-the practice of placing phrases or parts of speech next to each other without subordinating conjunctions. Sentences are juxtaposed without a clear connection; the contrast may generate novel and unexpected combinations between these dissimilar fragments. After distinguishing between parataxis and psychopathological phenomena like disturbances of association, I take inspiration from the work and life of a poet, Johann Christian Friedrich Hölderlin (1770-1843), considered among the greatest. He suffered for half his life from a severe form of mental illness that would perhaps, today, be diagnosed as schizophrenia. In the poems written during his illness, hypotaxis and narrative vigilance seem to blur, and parataxis takes centre stage. The fading of narrative structure in no way coincides with the absence of meaningfulness. Rather, meaningfulness is left to parataxis itself, that is, to the recombining power of words, sentences, and images. Parataxis itself can provide meaningfulness or, at least, provide the soil in which it can germinate. The void of narration opens the door for the fullness of "emergent" connections. In the final part of the paper, with the help of Freud's ideas on the relationship between "analysis" and "synthesis" in psychoanalytic treatment, some implications are derived about the relevance of parataxis to the logics of discovery in psychotherapeutic care, especially that of persons with severe mental conditions.

[Spatiotemporal psychopathology-German version of the Scale for Space and Time Experience in Psychosis (STEP) : A validated measurement instrument for the assessment of spatial and temporal experience in psychotic disorders]

Historical authors (e.g., Ludwig Binswanger and Eugène Minkowski) postulated that the experience of patients with schizophrenia is characterized by time fragmentation. From a clinical perspective, patients with schizophrenia also suffer from difficulties in spatial perception (e.g., abnormalities in the experience of interpersonal distance and spatial orientation). Although these changes can lead to a serious detachment from reality, to considerable suffering of the affected persons and to difficulties in the therapeutic process, the abnormal experience of space and time in psychotic disorders has not yet been sufficiently investigated. One possible reason is the lack of appropriate and standardized instruments that quantify the experience of space and time in patients with psychotic disorders. Based on an innovative concept, the so-called spatiotemporal psychopathology (STPP), a clinical rating scale for the systematic-quantitative assessment of spatial and temporal experience in patients with psychotic disorders was developed. This article presents the German version of the Scale for Space and Time Experience in Psychosis (STEP). The original English version of the STEP measures different spatial (14 phenomena) and temporal (11 phenomena) phenomena in 25 items. The STEP shows both a high internal consistency (Cronbach's alpha = 0.94) and a significant correlation with the Positive and Negative Syndrome Scale (PANSS; p < 0.001). In summary, the German version of the STEP scale presented here represents an important instrument in the German-speaking countries for the assessment of spatial and temporal experience in patients with psychotic disorders.

A seven-year longitudinal study of the association between neurocognitive function and basic self-disorders in schizophrenia

Introduction

Basic self-disorders (SDs) and neurocognitive impairments are fundamental trait-like aspects of schizophrenia spectrum disorders. There has been little research on the association between SDs and neurocognitive impairments in schizophrenia, and no longitudinal studies have investigated if they are related. The aim of this study was to investigate the association between SDs and neurocognitive function in a follow-up study of patients with schizophrenia.

Methods

SDs and neurocognition were examined in 35 patients with schizophrenia during their first treatment and 7 years later (mean 7.1, SD 0.42). SDs were examined with the Examination of Anomalous Self-Experience (EASE) instrument. The neurocognitive examination included assessments of psychomotor speed, executive- and memory functions.

Results

Poorer executive functions at baseline were significantly associated with more SDs 7 years later and smaller reductions in SDs over time. There were no significant associations between other neurocognitive functions and SDs.

Discussion

Executive functions are important for self-regulation, and impairments in these functions in everyday life may have an impact on the development and/or persistence of SDs.

Understanding subjective experience in psychedelic-assisted psychotherapy: The need for phenomenology

Psychedelic-assisted psychotherapy is being investigated as a treatment for a range of psychiatric illnesses. Current research suggests that the kinds of subjective experiences induced by psychedelic compounds play key roles in producing therapeutic outcomes. To date, most knowledge of therapeutic psychedelic experiences are derived from psychometric assessments with scales such as the Mystical Experience Questionnaire. While these approaches are insightful, more nuanced and detailed descriptions of psychedelic-induced changes to subjective experience are required. Drawing on recent advancements in qualitative methods arising from the interdisciplinary field of phenomenological psychopathology, we propose a systematic and comprehensive investigation into how psychedelic-assisted psychotherapy alters subjective experience. This research programme aims to characterise the nature of therapeutic psychedelic experiences by drawing on concepts from philosophical phenomenology. Such characterisations should, moreover, contribute to our understanding of the mechanisms of psychedelic therapy, the role of integration therapy, and related philosophical debates.

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.

Mapping Personal Geographies in Psychosis: From Space to Place

Recently, there has been a growing interest in the interaction between the urban milieu and the development of psychosis. While growing up in an urban environment constitutes a risk factor for developing psychosis, patients who develop a first episode of psychosis tend to avoid city centers and suffer from isolation. These observations have fostered emerging interest in ways of developing contexts in cities that are favorable to mental health and that may help service users in their paths to recovery. Building on work on place attachment as well as systemic therapy, we present a new approach to map the urban spaces experienced by service users. We propose two tools, the "place attachment diagram" and "life space network," to situate emotional bond and spatial dimension respectively at their center and help service users to map meaningful places in the city. We also suggest that different facets of the illness such as epidemiological risk factors (residential mobility, migration, urban living, trauma), early place attachment and abnormal space experience, may shape individual space and place experience in psychosis. Psychotherapeutic process with patients should aim at turning urban "spaces" into "places" characterized by a sense of familiarity, security and opportunity. Finally, we argue that the "spatial" is a forgotten dimension in psychotherapy and should be taken into account when treating individuals with psychosis.

Dear Body… An Explorative Study on Anomalous Bodily Experiences in Persons with Feeding and Eating Disorders

OBJECTIVE

The aim of the study was to provide a qualitative analysis of anomalous bodily experiences (ABEs) of persons affected by feeding and eating disorders (FEDs). In particular, this study aimed to refine the description of bodily experiences in persons with FEDs so as to improve their treatment.

SAMPLING AND METHODS

This is a naturalistic explorative study on a group of 29 patients affected by FED in psychotherapeutic treatment and 12 healthy controls. We asked the participants to write a letter on the way they experience their body. Later, we analysed their letters by means of consensual qualitative research.

RESULTS

All patients (29) reported at least 1 ABE. The main categories identified are (1) body-obstacle (the body interposes between the person and the world); (2) body-tyrant (the body imposes itself on the will of the person); (3) body-hyper-visible (the body is experienced as an exposed object); (4) body-geometric (the body is experienced or associated with a geometric form); and (5) body-numerical (the body is defined by numbers). All these categories are present in the clinical group, and they are absent in the control group.

CONCLUSION

To grasp the experiential nuances of ABEs is relevant to understand the disorder of embodied self-hood and personal identity in these patients and thus to refine clinical treatment.