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

The phenomenological model of depression: from methodological challenges to clinical advancements

In this article our overall aim is to illustrate how phenomenological psychopathology can advance the clinical work on depression. To do so, we start by unfolding the current phenomenological model of depression. We argue that this model faces a methodological challenge, which we define as 'the challenge of patho-description'. Mental disorders, such as depression, influence how people are able to access and describe their own experiences. This becomes a challenge for phenomenological psychopathology since its methodology is based on people's ability to describe their own experiences. To deal with this challenge, in the case of depression, we turn to the framework of phenomenological interview. We interview 12 participants (7 women, 5 men, age-range from 29 to 57 years) with moderate and severe depression. From the interview results, we show how phenomenological interview deals with the challenge of patho-description and how patho-description in depression conceals experiential nuances. We unfold these nuances and describe how people with depression pre-reflectively experience a variety of feelings, a type of agency, overly positive self-image, and relations in a hyper-social way. These descriptive nuances not only strengthen the phenomenological model of depression, but they also help advance the clinical work on depression. We firstly illustrate how the descriptive nuances can be added to current manuals and rating scales to advance diagnostic work. Secondly, we illustrate how phenomenological, 'bottom-up', and embodied approaches function at the pre-reflective level of experience, and that further effort at this level can help advance therapy for depression.

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

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

Pseudoneurotic symptoms in the schizophrenia spectrum: An empirical study

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Uncovering the realities of delusional experience in schizophrenia: a qualitative phenomenological study in Belgium

BACKGROUND

Delusions in schizophrenia are commonly approached as empirical false beliefs about everyday reality. Phenomenological accounts, by contrast, have suggested that delusions are more adequately understood as pertaining to a different kind of reality experience. How this alteration of reality experience should be characterised, which dimensions of experiential life are involved, and whether delusional reality might differ from standard reality in various ways is unclear and little is known about how patients with delusions value and relate to these experiential alterations. This study aimed to investigate the nature of delusional reality experience, and its subjective apprehension, in individuals with lived experience of delusions and a schizophrenia-spectrum diagnosis.

METHODS

In this qualitative phenomenological study, we recruited individuals with lived experience of delusions and a schizophrenia-spectrum diagnosis from two psychiatric-hospital services in Belgium using homogenous sampling. Criteria for participation were having undergone at least one psychotic episode with occurring delusional symptoms, present at least 1 year before participation, on the basis of clinical notes assessed by the attending psychiatrist; a schizophrenia-spectrum diagnosis, ascertained through clinical interview by the attending psychiatrist upon admission; being aged between 18 years and 65 years; and having the capacity to give informed consent. Exclusion criteria included worries concerning capacity to consent and risk of distress caused by participation. We did phenomenologically driven semi-structured interviews with the participants to explore the nature of delusional reality experience and their subjective valuation of these experiences. We used interpretative phenomenological analysis, a qualitative method tailored to the in-depth exploration of participants' first-person perspective, to analyse their accounts.

FINDINGS

Between March 2, 2020, and Sept 30, 2020, 18 adults (13 men and five women, aged 19-62 years) participated in the interview study. The findings suggest that delusions are often embedded in wide-ranging alterations of basic reality experience, involving quasi-ineffable atmospheric and ontological qualities that undermine participants' sense of the world as unambiguously real, fully present, and shared with others. We also found that delusional reality experience can differ from standard reality in various ways (ie, in a hypo-real and hyper-real form), across multiple dimensions (eg, meaningfulness, necessity and contingency, and detachment and engagement), and that participants are often implicitly or explicitly aware of the distinction between delusional and standard reality. Delusional experience can have an enduring value and meaning that is not fully captured by a strictly medical perspective.

INTERPRETATION

Increased awareness and recognition of the distinctive nature of delusional reality experience, in both clinical and research settings, can improve diagnostic accuracy, explanatory models, and therapeutic support for individuals with delusions whose lived realities are not always evident from an everyday perspective.

FUNDING

FWO Flanders.

TRANSLATION

For the Dutch translation of the abstract see Supplementary Materials section.

[Clinical and pathopsychological features of youth depression with attenuated schizophrenic symptoms]

OBJECTIVE

To determine the clinical and pathopsychological features of youth depressions with attenuated schizophrenic symptoms (ASS), and their significance for early differential diagnostic and nosological assessment.

MATERIAL AND METHODS

Twenty young patients (19.7±3.7 years) with the first depressive episode with attenuated schizophrenic symptoms (ASS) (ICD-10 items F32.1, F32.2, F32.3) (basic group) were divided into subgroup 1 with attenuated positive symptoms - APS (19.3%) and subgroup 2 with attenuated negative symptoms - ANS (45.1%). Eleven young patients (19.4±2.9 years) with the classic depressive episode without ASS (ICD-10 items F32.1, F32.2) were included in a control group. Psychometric scales HDRS, SOPS, SANS, pathopsychological methods and Adult Personality Traits Questionnaire (APTQ) were used.

RESULTS

Statistically significant differences in the severity of depression were not found. A higher SOPS total score (p=0.006) and a greater severity of negative symptoms on SANS (p=0.006) were detected in patients of clinical groups compared with the comparison group. Distortion of the generalization process was detected in 60% of cases, impairments of immediate memorization were found in 30%, and the non-constructive nature of associations in 10%. Indirect data on greater emotional integrity of patients from the comparison group was obtained.

CONCLUSION

The presence of similar clinical and psychological abnormalities in the youth depressions with ASS allows us to attribute these phenomena to the possible risk factors for the development of schizophrenia.

Delusions beyond beliefs: a critical overview of diagnostic, aetiological, and therapeutic schizophrenia research from a clinical-phenomenological perspective

Delusions are commonly conceived as false beliefs that are held with certainty and which cannot be corrected. This conception of delusion has been influential throughout the history of psychiatry and continues to inform how delusions are approached in clinical practice and in contemporary schizophrenia research. It is reflected in the full psychosis continuum model, guides psychological and neurocognitive accounts of the formation and maintenance of delusions, and it substantially determines how delusions are approached in cognitive-behavioural treatment. In this Review, we draw on a clinical-phenomenological framework to offer an alternative account of delusion that incorporates the experiential dimension of delusion, emphasising how specific alterations to self-consciousness and reality experience underlie delusions that are considered characteristic of schizophrenia. Against that backdrop, we critically reconsider the current research areas, highlighting empirical and conceptual issues in contemporary delusion research, which appear to largely derive from an insufficient consideration of the experiential dimension of delusions. Finally, we suggest how the alternative phenomenological approach towards delusion could offer new ways to advance current research and clinical practice.

Integrating clinical staging and phenomenological psychopathology to add depth, nuance, and utility to clinical phenotyping: a heuristic challenge

Psychiatry has witnessed a new wave of approaches to clinical phenotyping and the study of psychopathology, including the US National Institute of Mental Health's Research Domain Criteria, clinical staging, network approaches, the Hierarchical Taxonomy of Psychopathology, the general psychopathology factor, and a revival of interest in phenomenological psychopathology. The question naturally emerges about what the relationship between these new approaches is. Are they mutually exclusive and competing approaches, or can they be integrated in some way and be used to enrich each other? In this Personal View, we propose a possible integration between clinical staging and phenomenological psychopathology. Domains identified in phenomenological psychopathology (eg, selfhood, embodiment, and affectivity) can be overlaid on clinical stages to enrich and deepen the phenotypes captured in clinical staging (creating high-resolution clinical phenotypes). This approach might be useful both ideographically and nomothetically, to complement diagnosis, enrich clinical formulation, inform treatment of individual patients, and help to guide aetiology research, prediction of clinical trajectory and treatment. Overlaying phenomenological domains on clinical stages might require reformulating these domains in dimensional rather than categorial terms. This integrative project requires assessment tools (some of which are already available) that are sufficiently sensitive and thorough to pick up on the range of relevant psychopathology. The proposed approach offers opportunities for mutual enrichment: clinical staging might be enriched by introducing greater depth to phenotypes; phenomenological psychopathology might be enriched by introducing stages of severity and disorder progression to phenomenological analysis.

Exploring schizophrenia spectrum psychopathology in borderline personality disorder

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

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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.

Beyond the "at risk mental state" concept: transitioning to transdiagnostic psychiatry

The "at risk mental state" for psychosis approach has been a catalytic, highly productive research paradigm over the last 25 years. In this paper we review that paradigm and summarize its key lessons, which include the valence of this phenotype for future psychosis outcomes, but also for comorbid, persistent or incident non-psychotic disorders; and the evidence that onset of psychotic disorder can at least be delayed in ultra high risk (UHR) patients, and that some full-threshold psychotic disorder may emerge from risk states not captured by UHR criteria. The paradigm has also illuminated risk factors and mechanisms involved in psychosis onset. However, findings from this and related paradigms indicate the need to develop new identification and diagnostic strategies. These findings include the high prevalence and impact of mental disorders in young people, the limitations of current diagnostic systems and risk identification approaches, the diffuse and unstable symptom patterns in early stages, and their pluripotent, transdiagnostic trajectories. The approach we have recently adopted has been guided by the clinical staging model and adapts the original "at risk mental state" approach to encompass a broader range of inputs and output target syndromes. This approach is supported by a number of novel modelling and prediction strategies that acknowledge and reflect the dynamic nature of psychopathology, such as dynamical systems theory, network theory, and joint modelling. Importantly, a broader transdiagnostic approach and enhancing specific prediction (profiling or increasing precision) can be achieved concurrently. A holistic strategy can be developed that applies these new prediction approaches, as well as machine learning and iterative probabilistic multimodal models, to a blend of subjective psychological data, physical disturbances (e.g., EEG measures) and biomarkers (e.g., neuroinflammation, neural network abnormalities) acquired through fine-grained sequential or longitudinal assessments. This strategy could ultimately enhance our understanding and ability to predict the onset, early course and evolution of mental ill health, further opening pathways for preventive interventions.