Self-Disorders: Clinical and Conceptual Implications for the Diagnostic Concept of Schizophrenia

Schizophrenia

Schizophrenia, characterised by psychotic symptoms and in many cases social and occupational decline, remains an aetiological and therapeutic challenge. Contrary to popular belief, the disorder is modestly more common in men than in women. Nor is the outcome uniformly poor. A division of symptoms into positive, negative, and disorganisation syndromes is supported by factor analysis. Catatonic symptoms are not specific to schizophrenia and so-called first rank symptoms are no longer considered diagnostically important. Cognitive impairment is now recognised as a further clinical feature of the disorder. Lateral ventricular enlargement and brain volume reductions of around 2% are established findings. Brain functional changes occur in different subregions of the frontal cortex and might ultimately be understandable in terms of disturbed interaction among large-scale brain networks. Neurochemical disturbance, involving dopamine function and glutamatergic N-methyl-D-aspartate receptor function, is supported by indirect and direct evidence. The genetic contribution to schizophrenia is now recognised to be largely polygenic. Birth and early life factors also have an important aetiological role. The mainstay of treatment remains dopamine receptor-blocking drugs; a psychological intervention, cognitive behavioural therapy, has relatively small effects on symptoms. The idea that schizophrenia is better regarded as the extreme end of a continuum of psychotic symptoms is currently influential. Other areas of debate include cannabis and childhood adversity as causative factors, whether there is progressive brain change after onset, and the long-term success of early intervention initiatives.

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

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

Anomalous self-experiences in cognition are negatively associated with neurocognitive functioning in schizophrenia

INTRODUCTION

Anomalous self-experiences (ASEs) are disturbances in the subjective experience of the self and are common in people with schizophrenia. Theorists have suggested that ASEs may underlie the neurocognitive deficits that are also common in people with schizophrenia; however, few studies have empirically investigated the relationship between these variables. Thus, the current study aimed to determine whether self-reported ASEs, particularly disturbances in cognitive or mental experiences, are meaningfully related to neurocognitive performance in individuals with schizophrenia.

METHODS

48 individuals with schizophrenia and 34 healthy comparison participants completed the Inventory of Psychotic-Like Anomalous Experiences (IPASE), which is composed of five subscales including disturbances in cognition, and the MATRICS Consensus Cognitive Battery (MCCB).

RESULTS

Participants with schizophrenia performed worse than controls on each MCCB domain and had higher ASE scores on the total IPASE and all five subscales. Only the IPASE-Cognition subscale was associated with cognitive performance. Specifically, IPASE-Cognition was negatively correlated with scores in attention, visual learning, reasoning, and working memory.

CONCLUSIONS

These results suggest that self-reported subjective disturbances in cognition may be meaningfully associated with several objectively-measured domains of neurocognition. Severity of ASEs may therefore be an important consideration when analysing the extent of cognitive deficits in schizophrenia.

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

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

Understanding Identity Changes in Psychosis: A Systematic Review and Narrative Synthesis

BACKGROUND AND OBJECTIVE

Experiencing psychosis can be associated with changes in how people see themselves as individuals and in relation to others (ie, changes in their identity). However, identity changes receive little attention in treatment, possibly due to a lack of clarity or consensus around what identity change means in people with psychosis. We aimed to create a conceptual framework synthesizing how identity changes are understood in the psychosis literature.

METHODS

Electronic databases were searched up to April 2020. Studies about identity changes among people with psychotic disorders were analyzed using narrative synthesis by a collaborative review team, including researchers from different disciplines, clinicians, and people who have experienced psychosis.

RESULTS

Of 10 389 studies screened, 59 were eligible. Identity changes are understood in 5 ways as (1) characteristics of psychosis, (2) consequences of altered cognitive functioning, (3) consequences of internalized stigma, (4) consequences of lost roles and relationships, and (5) reflections of personal growth. These 5 understandings are not mutually exclusive. Across a heterogeneous literature, identity changes were mostly framed in terms of loss.

CONCLUSIONS

Our conceptual framework, comprising 5 understandings, highlights the complexity of studying identity changes and suggests important implications for practice and research. For clinicians, this framework can inform new therapeutic approaches where the experience and impact of identity changes are acknowledged and addressed as part of treatment. For researchers, the conceptual framework offers a way of locating their understandings of identity changes when undertaking research in this area.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Psychotic conversion of individuals at ultra-high risk for psychosis: The potential roles of schizotypy and basic symptoms

AIM

To improve strategies for the early identification of individuals at a heightened risk for the development of psychosis, we investigated the relationships and interactions between 3 psychosis-proneness dimensions for the development of schizophrenia spectrum psychosis: schizotypy, basic symptoms and the ultra-high risk (UHR) criteria.

METHODS

Seventy-seven UHR individuals and 79 healthy controls were assessed for schizotypy and basic symptoms using self-report questionnaires at baseline. UHR participants were monthly assessed for conversion to psychosis over a mean period of 25.8 months.

RESULTS

Sixteen UHR participants (20.8%) converted to schizophrenia spectrum psychosis. In stepwise Cox regression, the interaction between basic symptoms and physical anhedonia was selected as a sole predictor of conversion in UHR participants, whereby the self-reported number of the 8 basic symptoms significantly increased the risk for conversion in those with pronounced physical anhedonia.

CONCLUSION

Our findings suggest that questionnaire-assessed basic symptoms, irrespective of their predictive validity, may predict a psychotic breakdown in pre-identified UHR individuals who are with genetic vulnerability to schizophrenia. Including all 3 psychosis-proneness dimensions into prediction models might help establish a more valid pathogenetic model of schizophrenia, and moreover, may provide some clues about course alteration strategies in hopes of preventing UHR individuals from converting to psychosis.

A combination of self-disturbances and psychotic-like experiences. A cluster analysis study on a non-clinical sample in Poland

We aimed to perform a cluster analysis to investigate the group structure of a combination of psychotic-like experiences (PLEs) and self-disturbances in a non-clinical sample. Non-clinical adults (n = 677) were assessed with the Community Assessment of Psychic Experiences (CAPE), the Davos Assessment of Cognitive Biases Scale (DACOBS) and the Inventory of Psychotic-Like Anomalous Self-Experiences (IPASE). Cluster analysis was conducted based on the positive and negative dimension of CAPE and a total score of IPASE. Four distinct groups were revealed by the cluster analysis. The High Profile group had the highest means, and the Low Profile had the lowest scores of positive and negative subscales of the CAPE and IPASE. The Positive Profile group had a significantly higher level of self-disturbances (in 'Cognition', 'Consciousnesses and 'Somatization' dimensions) from participants with the 'Negative Profile'. The High Profile group had more cognitive biases (i.e., inadequate cognitive inference about internal and external events) related to psychosis as assessed with DACOBS, had the highest means on each IPASE subscale and had a higher level of emotional distress. A combination of high level of PLEs and self-disturbances may capture the highest risk of psychosis in the general population associated with cognitive biases characteristic for psychosis.

The role of self-disturbances and cognitive biases in the relationship between traumatic life events and psychosis proneness in a non-clinical sample

BACKGROUND

Traumatic life events have been established as an environmental risk factor for psychosis. However, the exact mechanisms by which traumatic life events increase risk for psychosis are unknown. In the present study we tested an integrative model of traumatic life events being related to psychosis proneness via self-disturbances and cognitive biases.

METHODS

The sample consisted of 653 healthy people. Traumatic life events, self-disturbances, cognitive biases and psychosis proneness were assessed with self-report questionnaires. The direct and an indirect model of the relationship between traumatic life events and psychosis proneness were compared using path analyses with structural equation modelling in a cross-sectional study.

RESULTS

There was a significant direct effect of traumatic life events on psychosis proneness. However, path analysis suggested better fit of the indirect model including paths from trauma to psychosis proneness via cognitive biases and self-disturbances. There were significant paths from traumatic life events to cognitive biases and self-disorders. Self-disorders significantly predicted cognitive biases. Finally, cognitive biases and self-disorders significantly predicted psychosis proneness. Exclusion of any paths, apart from direct path in the model, significantly reduced model fitness.

DISCUSSION

The results revealed that a direct relationship between trauma and psychosis proneness became insignificant when taking into account the influence of self-disorders and cognitive biases. This suggests that the interactions between disrupted self-experience, impaired information processing and traumatic life events are of importance in psychosis proneness. This model should be further tested in a longitudinal study on a clinical sample.

[Psychiatry of the future: multidimensionality of the problems of modern psychiatry and development of classification systems]

The success and achievements in the area of neurosciences due to the development of neuroimaging, neurochemical and genome studies provide tasks for psychiatry determined by the necessity to develop new classifications of mental diseases, primarily ICD-11, specify clinical diagnostic criteria and rethink the essence of some mental disorders. In spite of the multiple direction of scientific opinions on the discussed issues, the development of modern psychiatry is characterized by intensive search of biological background of psychiatric disorders and elaboration of effective approaches to the diagnosis and treatment of mental diseases, including medical rehabilitation of patients.

Genetics of Schizophrenia: Overview of Methods, Findings and Limitations

Genetics constitute a crucial risk factor to schizophrenia. In the last decade, molecular genetic research has produced novel findings, infusing optimism about discovering the biological roots of schizophrenia. However, the complexity of the object of inquiry makes it almost impossible for non-specialists in genetics (e.g., many clinicians and researchers) to get a proper understanding and appreciation of the genetic findings and their limitations. This study aims at facilitating such an understanding by providing a brief overview of some of the central methods and findings in schizophrenia genetics, from its historical origins to its current status, and also by addressing some limitations and challenges that confront this field of research. In short, the genetic architecture of schizophrenia has proven to be highly complex, heterogeneous and polygenic. The disease risk is constituted by numerous common genetic variants of only very small individual effect and by rare, highly penetrant genetic variants of larger effects. In spite of recent advances in molecular genetics, our knowledge of the etiopathogenesis of schizophrenia and the genotype-environment interactions remain limited.

White matter integrity and symptom dimensions of schizophrenia: A diffusion tensor imaging study

Impaired fiber bundle connectivity between brain regions is a key neuropathological finding in schizophrenia. Symptom dimensions in schizophrenia can be clustered into factor models. Single syndromes have been related to grey and white matter brain structure alterations. We associated all core syndromes of schizophrenia in a single patient group with changes in white matter integrity. Diffusion weighted images (3T MRI) and SAPS/SANS scores were measured in 26 male patients and 26 healthy controls. First, group differences in fractional anisotropy (FA) were calculated with TBSS. Second, core symptom dimensions of schizophrenia were correlated with FA within these altered tracts. We found differences between groups in nine white matter tracts. Hallucinations were positively correlated with FA in the left uncinate fasciculus and left corticospinal tract. Ego-disturbances (passivity phenomena) showed a positive correlation with FA in the right anterior thalamic radiation. Positive formal thought disorders (FTD) corresponded negatively with FA in the right cingulum bundle. Negative symptoms were positively associated with the right anterior thalamic radiation and negatively with the right ventral cingulum bundle. For the first time, we analyzed the whole range of psychopathological factors in one schizophrenia patient group. We could validate our novel results for positive FTD and passivity phenomena by replicating findings for hallucinations and negative symptoms. Only those brain circuits which are most vulnerable at a given time during neurodevelopment are affected by a particular pathological impact (genetic, environmental). This scenario could explain the predominance of particular psychopathological syndromes related to specific white matter anomalies.

Exploring a lay Gestalt of schizophrenia? A Danish background population’s explanations on why and how first-episode schizophrenia patients’ narratives were intuitively sensed as contextually inappropriate

Background

Recent continental-phenomenological psychiatry emphasizes pragmatics or social and contextual inappropriateness as a core disorder of schizophrenia, which is potentially relevant to early identification and treatment.

Objective

However, there are hardly any studies that examine the background population’s sensitivity to inappropriateness in schizophrenia, even if “common” people, from a pragmatic perspective, are likely to be highly sensitive to cultural-conventional norms, including (in)appropriateness.

Method

One empirical evaluation of contextual (in)appropriateness in 10 narratives from first-episode schizophrenia patients and healthy controls, respectively, found that when a phenomenologically informed Danish population (n=157 high-school students; mean age, 18.5) was “blinded” to the control–patient status – that is, “anonymous” narratives of the wordless picture story Frog, Where Are You? – they consequently evaluated patient narratives as more inappropriate than appropriate and control narratives as more appropriate than inappropriate (significant with 0.007). Aiming to explore a potential pattern recognition, distinguishing patient from control narratives, the present study systematizes and discusses salient explanations from lay “experts” who almost consequently (80% to 100%) evaluated patient narratives as inappropriate and control narratives as appropriate (n=63 of 157).

Results

Explanations of inappropriateness concerned affective aspects (about how the patient felt or how the evaluators felt reading the narrative), formal aspects (about pauses, fluency, and brevity), and aspects about sense making (from lack of understanding to nonsense and strangeness).The background population may be sensitive to affective and formal inappropriateness, but only lay experts emphasize the lack of sense in the patients’ narratives.

Conclusion

Further studies might benefit from investigating whether early referrals from family, friends, or schoolteachers of their own accord thematize such inappropriateness aspects, and whether questionnaires targeting inappropriateness could be developed and used in the early identification of young people at risk.

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

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