Stop, look, listen: the need for philosophical phenomenological perspectives on auditory verbal hallucinations

More phenomenology in psychiatry? Applied ontology as a method towards integration

There have been renewed calls to use phenomenology in psychiatry to improve knowledge about causation, diagnostics, and treatment of mental health conditions. A phenomenological approach aims to elucidate the subjective experiences of mental health, which its advocates claim have been largely neglected by current diagnostic frameworks in psychiatry (eg, DSM-5). The consequence of neglecting rich phenomenological information is a comparatively more constrained approach to theory development, empirical research, and care programmes. Although calls for more phenomenology in psychiatry have been met with enthusiasm, there is still relatively little information on how to practically facilitate this integration. In this Personal View, we argue that phenomenological approaches need a shared semantic framework to drive their innovative potential, thus enabling consistent data capture, exchange, and interoperability with current mental health data and informatics approaches (eg, the Research Domain Criteria project). We show how an applied ontology of phenomenological psychopathology offers a suitable method to address these challenges.

Disembodied Language in Early-Onset Schizophrenia

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

Psychotic-like experiences? Trajectories and typologies of hallucinations and delusions from early adolescence to early adulthood in a population-based sample of Irish youth

OBJECTIVES

Hallucinations and delusions that occur in the absence of a psychotic disorder are common in children and adolescents. Longitudinal phenomenological studies exploring these experiences are notably lacking. The objective of the current paper was to explore the phenomenology and characteristics of hallucinations and delusions from early adolescence to early adulthood.

METHODS

Participants were 17 young people aged 18-21 years from the general population, all of whom had a history of childhood hallucinations and/or delusions. Longitudinal data on the phenomenological characteristics and attributions of reported hallucinatory and delusional phenomena spanning nine years were explored using content analysis.

RESULTS

Hallucinatory and delusional phenomena were transient for two-thirds of the sample. The remaining one-third reported reoccurring hallucinatory and delusional phenomena into early adulthood. In those, two typologies were identified: (1) Paranormal typology and (2) Pathological typology. The former was characterised by hallucinatory and delusional phenomena that were exclusively grounded in subcultural paranormal or spiritual belief systems and not a source of distress. The latter was characterised by delusion-like beliefs that were enmeshed with individuals' mood states and a source of distress. The perceived source, the subcultural context and how young people appraised and integrated their experiences differentiated the Paranormal and Pathological typologies.

CONCLUSIONS

Not all hallucinatory and delusion-like experiences are psychotic-like in nature. To reliably differentiate between pathological and non-pathological hallucinations and delusions, assessments need to explore factors including the phenomenology of individuals' experiences, how people make sense and appraise them, and the subcultural contexts within which they are experienced.

Validation of the Hamilton Program for Schizophrenia Voices Questionnaire: Associations with emotional distress and wellbeing, and invariance across diagnosis and sex

BACKGROUND

Voice-hearing is a transdiagnostic experience with evident negative effects on patients. Good quality measurement is needed to further elucidate the nature, impact and treatment of voice-hearing experiences across patient groups. The Hamilton Program for Schizophrenia Voices Questionnaire (HPSVQ) is a brief self-report measure which requires further psychometric evaluation.

METHODS

Using data from a transdiagnostic sample of 401 adult UK patients, the fit of a conceptual HPSVQ measurement model, proposing a separation between physical and emotional voice-hearing characteristics, was tested. A structural model was examined to test associations between voice-hearing, general emotional distress (depression, anxiety, stress) and wellbeing. The invariance of model parameters was examined across diagnosis and sex.

RESULTS

The final measurement model comprised two factors named 'voice severity' and 'voice-related distress'. The former comprised mainly physical voice characteristics and the latter mainly distress and other negative impacts. Structural model results supported voice-related distress as mediating the associations between voice severity and emotional distress and wellbeing. Model parameters were invariant across psychosis versus non-psychosis diagnosis and partially invariant across sex. Females experienced more severe and distressing voices and a more direct association between voice severity and general anxiety was evident.

CONCLUSIONS

The HPSVQ is a useful self-report measure of voice-hearing with some scope for further exploration and refinement. Voice-related distress appears a key mechanism by which voice severity predicts general distress and wellbeing. Whilst our data broadly support interventions targeting voice-related distress for all patients, females may benefit especially from interventions targeting voice severity and strategies for responding.

The auditory-verbal hallucinations of Welsh-English bilingual people

OBJECTIVES

Psychological models of voice-hearing propose that auditory-verbal hallucinations occur when inner speech is attributed to a source external to the self. Approximately half of the world's population is multilingual, and the extent to which they use a second language for inner speech depends on their experience and competency in it. Bilingualism therefore provides a natural window into the processes operating in auditory-verbal hallucinations, but no systematic study of voice-hearing in bilinguals has hitherto been conducted.

DESIGN

A mixed-methods observational study of psychiatric service users who hear voices and who are Welsh-English bilingual.

METHODS

Thirty-seven participants were interviewed about their history and use of Welsh and English and divided into three groups: those who learnt Welsh first (L1 Welsh), those who learnt English first (L1 English), and those who learnt the two languages simultaneously. Detailed phenomenological data were collected using The Mental Health Research Institute Unusual Perceptions Schedule.

RESULTS

Both qualitative and quantitative data indicated very considerable variation in the extent to which voices were in Welsh, English, or both, with some voice-hearers reporting that the predominant language of their voices had changed with time. There were modest but statistically significant associations between the predominant language of voices and age of language acquisition (late Welsh learners did not hear voices in Welsh), frequency of language use (more frequent use of Welsh was associated with more Welsh voices), and subjective language proficiency (proficiency in English was associated with a tendency to hear English voices).

CONCLUSIONS

Although this was a small study, it was the first of its kind. There is a need for more research on the implications of bilingualism for psychosis in particular and mental illness more generally. The results are broadly consistent with the hypothesis that hallucinated voices are misattributed inner speech.

PRACTITIONER POINTS

Assessments of people with mental health difficulties should routinely inquire whether they are multilingual and, if so, which language they prefer to use. People with mental health difficulties may have difficulty expressing complex issues and emotions in a second language, despite apparent fluency. When working with bilingual people who hear voices, mental health professionals should consider the language used by the voices when conducting assessments and proposing formulations.

The Phenomenon of "Hearing Voices": Not Just Psychotic Hallucinations-A Psychological Literature Review and a Reflection on Clinical and Social Health

The phenomenon of hearing voices is currently a much-discussed topic, both in the field of research and in the field of care services. The majority of people who report "hearing voices" do not subsequently receive services or receive a diagnosis of psychopathology. This topic raises questions for professionals in the health field about the lack of tools that can help illuminate the phenomenon. The purposes of this work are (a) to highlight the psychological studies that approach the phenomenon in a non-psychopathological way and (b) to determine which concepts could aid the comprehension of the phenomenon. The method consists of a systematic review of the literature that characterizes the phenomenon of hearing voices from a non-pathological perspective. The literature offers different theoretical approaches to interpret the phenomenon in a way that is not necessarily pathological and presents new tools for examining the phenomenon. For example, a few studies state that it is possible to coexist with voices, while others indicate that it is necessary to know how to manage voices. We highlighted and discussed several concepts that can support doctors, psychiatrists and practitioners in understanding "hearer" patients, particularly attention to the context of belonging, attention to language, and the role of the sense-making process.

Characterizing the experience of auditory verbal hallucinations and accompanying delusions in individuals with a diagnosis of bipolar disorder: A systematic review

OBJECTIVES

The aim of the current study was to inform ongoing attempts to identify clinically meaningful subcategories of auditory verbal hallucination (AVH), and to evaluate evidence that might pertain to the suitability of current psychological interventions for people with bipolar disorder (BD) who experience psychotic symptoms.

METHODS

A comprehensive synthesis of findings on the phenomenology of AVH and delusions in BD is included, alongside a critical review of clinical and cognitive correlates. Studies published in the previous 20 years, until December 2016, were retrieved from the following databases: Embase, CINAHL, MEDLINE, PsycINFO and Web of Science. Thirty-two articles were reviewed after applying a set of predetermined inclusion criteria.

RESULTS

Psychotic symptoms were common in both manic and depressive phases, although higher frequencies were indicated in mania. Few detailed characterizations of AVH phenomenology were identified. Delusions with persecutory, grandiose and referential themes were the most common in BD. AVHs were associated with delusions and there was evidence to suggest that delusion subtype may vary according to mood state and type of AVH. Data on clinical correlates of AVH in BD were sparse. However, the results indicated that cognitive appraisals or interpretations of voices might be different in BD from those established to be predictive of clinical outcomes in schizophrenia spectrum disorders.

CONCLUSIONS

Clear gaps exist in our current understanding of the first-person experience of AVH in BD and the potential relationship to co-occurring symptoms, including delusions. Further research into cognitive interpretations of AVH in BD might inform adapted psychological interventions for psychotic symptoms in this population.

Understanding auditory verbal hallucinations: a systematic review of current evidence

OBJECTIVE

Auditory verbal hallucinations (AVHs) are core features of psychotic illness and remain significant in predicting poor outcome and risk. There has been a wide range of approaches to understanding these experiences.

METHOD

A systematic literature review summarizing different methods of investigation and their results; phenomenology, descriptive psychopathology, psychological, cognitive neurobiology, and neuroimaging.

RESULTS

A number of 764 papers and texts were screened and 113 reviewed. Phenomenological studies are comparably few in number, and psychopathology remains based on concepts defined in the early 20th century. Psychological models focus on voice content and emotional reaction, and suggest a continuum of AVHs from normal experience. Neuropsychological models include AVHs as misattribution of inner speech, whilst functional neuroimaging studies focus on the spontaneous activity and connectivity of auditory networks.

CONCLUSION

There has been a large growth in research on AVHs in recent decades dominated by neurobiological and neuroimaging studies. Future research should include focus on phenomenological aspects and AVHs change over the course of developing illness. Integration between branches of enquiry is needed, and the risk is that without this, models are proposed and investigated that bear scant relevance to the symptom itself.

The intrasubjectivity of self, voices and delusions: A phenomenological analysis

To advance the area of phenomenology of voices and their interrelatedness to forms of delusions this study investigated the prevalence and interrelatedness of co-occurring auditory verbal hallucinations (AVHs) and delusions. Additionally we explored the characterization of distinct sub-categories/clusters of AVHs and delusions. Ninety-two participants experiencing psychosis were administered standardized clinical measures. We found a significant diagnostic difference with increased prevalence of co-occurring AVHs and delusions within the schizophrenia group compared to the bipolar with psychosis group. Regardless of diagnosis, there was a significant positive correlation between AVHs and delusions of reference, persecution, control, thought insertion, thought withdrawal and thought broadcasting. However, no significant relationship was found between AVHs and grandiose, somatic, religious, guilty or jealousy-themed delusions. Cluster analysis yielded two distinct cluster groups. Cluster One: Voices and Thought Delusions, and Cluster Two: Voices and Thematic Delusions. Cluster One participants showed elevated disorganized, cognitive and depressive symptoms, but not negative symptoms or excitement. This study underscores the need for expanded clinical and phenomenological research into the intersection of AVHs and delusions, including work that seeks to deconstruct conventional divisions between ostensible symptoms of perception' (hallucinations) and belief' (delusions).

"Who is talking to me?" - Self-other attribution of auditory hallucinations and sulcation of the right temporoparietal junction

Brain imaging research in schizophrenia has provided a better understanding of the neural basis of auditory hallucinations (AH). Recently, renewed interest in the phenomenology of AH raised questions related to their neural substrates. Hence, the neural basis of AH self/other attribution have yet to be investigated as beliefs regarding the origin of the voices is a cardinal feature of AH phenomenology. As the right temporoparietal junction (TPJ) and the inferior parietal lobule (IPL) play a key role in disentangling the origin of sensory events and in self/other distinction, we tested the hypothesis that the morphology of the IPL/TPJ area may be involved in AH self/other attribution. Magnetic resonance images of 39 right-handed patients with persistent auditory hallucinations and 19 healthy subjects were analyzed with sulcus-based morphometry. AH self-other attribution were found to be associated with the sulcal pattern of the posterior part of the Sylvian fissure, encompassing the IPL/TPJ area. The preference for the attribution of AH to self or to others could be associated with early neurodevelopmental events as the sulcal pattern is determined during fetal life and is stable after birth. Our study also raises basic cognitive questions regarding self-consciousness and suggest that impairments at a pre-reflexive level, leading to hearing his/her thoughts as voices ('I' level or feeling of agency), and a reflexive level leading to attribution belief ('Me' level or judgment of agency) are likely involved in AH.

Bringing the "self" into focus: conceptualising the role of self-experience for understanding and working with distressing voices

A primary goal of cognitive behavior therapy for psychosis (CBTp) is to reduce distress and disability, not to change the positive symptoms of psychosis, such as hearing voices. Despite demonstrated associations between beliefs about voices and distress, the effects of CBTp on reducing voice distress are disappointing. Research has begun to explore the role that the psychological construct of "self" (which includes numerous facets such as self-reflection, self-schema and self-concept) might play in causing and maintaining distress and disability in voice hearers. However, attempts to clarify and integrate these different perspectives within the voice hearing literature, or to explore their clinical implications, are still in their infancy. This paper outlines how the self has been conceptualised in the psychosis and CBT literatures, followed by a review of the evidence regarding the proposed role of this construct in the etiology of and adaptation to voice hearing experiences. We go on to discuss some of the specific intervention methods that aim to target these aspects of self-experience and end by identifying key research questions in this area. Notably, we suggest that interventions specifically targeting aspects of self-experience, including self-affection, self-reflection, self-schema and self-concept, may be sufficient to reduce distress and disruption in the context of hearing voices, a suggestion that now requires further empirical investigation.

The linguistics of schizophrenia: thought disturbance as language pathology across positive symptoms

We hypothesize that linguistic (dis-)organization in the schizophrenic brain plays a more central role in the pathogenesis of this disease than commonly supposed. Against the standard view, that schizophrenia is a disturbance of thought or selfhood, we argue that the origins of the relevant forms of thought and selfhood at least partially depend on language. The view that they do not is premised by a theoretical conception of language that we here identify as 'Cartesian' and contrast with a recent 'un-Cartesian' model. This linguistic model empirically argues for both (i) a one-to-one correlation between human-specific thought or meaning and forms of grammatical organization, and (ii) an integrative and co-dependent view of linguistic cognition and its sensory-motor dimensions. Core dimensions of meaning mediated by grammar on this model specifically concern forms of referential and propositional meaning. A breakdown of these is virtually definitional of core symptoms. Within this model the three main positive symptoms of schizophrenia fall into place as failures in language-mediated forms of meaning, manifest either as a disorder of speech perception (Auditory Verbal Hallucinations), abnormal speech production running without feedback control (Formal Thought Disorder), or production of abnormal linguistic content (Delusions). Our hypothesis makes testable predictions for the language profile of schizophrenia across symptoms; it simplifies the cognitive neuropsychology of schizophrenia while not being inconsistent with a pattern of neurocognitive deficits and their correlations with symptoms; and it predicts persistent findings on disturbances of language-related circuitry in the schizophrenic brain.

Self, Voices and Embodiment: A Phenomenological Analysis

OBJECTIVE

The primary aim of this study was to examine first-person phenomenological descriptions of the relationship between the self and Auditory Verbal Hallucinations (AVHs). Complex AVHs are frequently described as entities with clear interpersonal characteristics. Strikingly, investigations of first-person (subjective) descriptions of the phenomenology of the relationship are virtually absent from the literature.

METHOD

Twenty participants with psychosis and actively experiencing AVHs were recruited from the University of Illinois at Chicago. A mixed-methods design involving qualitative and quantitative components was utilized. Following a priority-sequence model of complementarity, quantitative analyses were used to test elements of emergent qualitative themes.

RESULTS

The qualitative analysis identified three foundational constructs in the relationship between self and voices: 'understanding of origin,' 'distinct interpersonal identities,' and 'locus of control.' Quantitative analyses further supported identified links of these constructs. Subjects experienced their AVHs as having identities distinct from self and actively engaged with their AVHs experienced a greater sense of autonomy and control over AVHs.

DISCUSSION

Given the clinical importance of AVHs and emerging strategies targeting the relationship between the hearer and voices, our findings highlight the importance of these relational constructs in improvement and innovation of clinical interventions. Our analyses also underscore the value of detailed voice assessments such as those provided by the Maastricht Interview are needed in the evaluation process. Subjects narratives shows that the relational phenomena between hearer and AVH(s) is dynamic, and can be influenced and changed through the hearers' engagement, conversation, and negotiation with their voices.

Experiences of hearing voices: analysis of a novel phenomenological survey

BACKGROUND

Auditory hallucinations--or voices--are a common feature of many psychiatric disorders and are also experienced by individuals with no psychiatric history. Understanding of the variation in subjective experiences of hallucination is central to psychiatry, yet systematic empirical research on the phenomenology of auditory hallucinations remains scarce. We aimed to record a detailed and diverse collection of experiences, in the words of the people who hear voices themselves.

METHODS

We made a 13 item questionnaire available online for 3 months. To elicit phenomenologically rich data, we designed a combination of open-ended and closed-ended questions, which drew on service-user perspectives and approaches from phenomenological psychiatry, psychology, and medical humanities. We invited people aged 16-84 years with experience of voice-hearing to take part via an advertisement circulated through clinical networks, hearing voices groups, and other mental health forums. We combined qualitative and quantitative methods, and used inductive thematic analysis to code the data and χ(2) tests to test additional associations of selected codes.

FINDINGS

Between Sept 9 and Nov 29, 2013, 153 participants completed the study. Most participants described hearing multiple voices (124 [81%] of 153 individuals) with characterful qualities (106 [69%] individuals). Less than half of the participants reported hearing literally auditory voices--70 (46%) individuals reported either thought-like or mixed experiences. 101 (66%) participants reported bodily sensations while they heard voices, and these sensations were significantly associated with experiences of abusive or violent voices (p=0·024). Although fear, anxiety, depression, and stress were often associated with voices, 48 (31%) participants reported positive emotions and 49 (32%) reported neutral emotions. Our statistical analysis showed that mixed voices were more likely to have changed over time (p=0·030), be internally located (p=0·010), and be conversational in nature (p=0·010).

INTERPRETATION

This study is, to our knowledge, the largest mixed-methods investigation of auditory hallucination phenomenology so far. Our survey was completed by a diverse sample of people who hear voices with various diagnoses and clinical histories. Our findings both overlap with past large-sample investigations of auditory hallucination and suggest potentially important new findings about the association between acoustic perception and thought, somatic and multisensorial features of auditory hallucinations, and the link between auditory hallucinations and characterological entities.

FUNDING

Wellcome Trust.

Carving versus Stitching: The Concept of Psychic Function and the Continuity/Discontinuity Debate

BACKGROUND

The current debate on the continuity or discontinuity of psychotic symptoms and common psychic experiences has mainly dealt with methodological, epidemiological and clinical issues, but it has neglected epistemological research on the main concepts of the field.

METHODS

The implicit epistemic structure of continuity models of psychotic symptoms and its effect on research are addressed.

RESULTS

We explain how the seemingly commonsense, unproblematic concept of psychic function may explain the contradictions and paradoxes of research.

CONCLUSIONS

A new model of symptom individuation and symptom eliciting is proposed - based on the concepts of 'schemas', 'embodied affordances' and 'thick/thin descriptions'.

Interdisciplinarity as cognitive integration: auditory verbal hallucinations as a case study

In this article, we advocate a bottom-up direction for the methodological modeling of interdisciplinary research based on concrete interactions among individuals within interdisciplinary projects. Drawing on our experience in Hearing the Voice (a cross-disciplinary project on auditory verbal hallucinations running at Durham University), we focus on the dynamic if also problematic integration of cognitive science (neuroscience, cognitive psychology, and of mind), phenomenology, and humanistic disciplines (literature, narratology, history, and theology). We propose a new model for disciplinary integration which brings to the fore an under-investigated dynamic of interdisciplinary projects, namely their being processes of distributed cognition and cognitive integration. WIREs Cogn Sci 2014, 5:603-612. doi: 10.1002/wcs.1305 For further resources related to this article, please visit the WIREs website.

CONFLICT OF INTEREST

The authors have declared no conflicts of interest for this article.

Interdisciplinary approaches to the phenomenology of auditory verbal hallucinations

Despite the recent proliferation of scientific, clinical, and narrative accounts of auditory verbal hallucinations (AVHs), the phenomenology of voice hearing remains opaque and undertheorized. In this article, we outline an interdisciplinary approach to understanding hallucinatory experiences which seeks to demonstrate the value of the humanities and social sciences to advancing knowledge in clinical research and practice. We argue that an interdisciplinary approach to the phenomenology of AVH utilizes rigorous and context-appropriate methodologies to analyze a wider range of first-person accounts of AVH at 3 contextual levels: (1) cultural, social, and historical; (2) experiential; and (3) biographical. We go on to show that there are significant potential benefits for voice hearers, clinicians, and researchers. These include (1) informing the development and refinement of subtypes of hallucinations within and across diagnostic categories; (2) "front-loading" research in cognitive neuroscience; and (3) suggesting new possibilities for therapeutic intervention. In conclusion, we argue that an interdisciplinary approach to the phenomenology of AVH can nourish the ethical core of scientific enquiry by challenging its interpretive paradigms, and offer voice hearers richer, potentially more empowering ways to make sense of their experiences.

Studying hallucinations within the NIMH RDoC framework

We explore how hallucinations might be studied within the National Institute of Mental Health (NIMH) Research Domain Criteria (RDoC) framework, which asks investigators to step back from diagnoses based on symptoms and focus on basic dimensions of functioning. We start with a description of the objectives of the RDoC project and its domains and constructs. Because the RDoC initiative asks investigators to study phenomena across the wellness spectrum and different diagnoses, we address whether hallucinations experienced in nonclinical populations are the same as those experienced by people with psychotic diagnoses, and whether hallucinations studied in one clinical group can inform our understanding of the same phenomenon in another. We then discuss the phenomenology of hallucinations and how different RDoC domains might be relevant to their study. We end with a discussion of various challenges and potential next steps to advance the application of the RDoC approach to this area of research.

'I divide life into different dimensions, one mental and one physical, to be able to handle life, you know?' Subjective accounts of the content of psychotic symptoms

BACKGROUND

Previous research indicates that the content of psychotic symptoms is of significant importance for the individual who experiences them. However, there are limitations concerning the use of self-report instruments for capturing experiences that are of highly personal nature. The aim of this study was to provide a deeper understanding of how individuals with psychosis make sense of the content of their psychotic symptoms.

METHOD

Semi-structured interviews were conducted with 12 individuals, some of whom were experiencing active symptoms and some of whom had experienced symptoms within the last 12 months. The interviews explored the individuals' understanding of psychotic symptoms in terms of the content and the possible meaning of the content. All participants were patients at a unit specializing in psychosis. The study applied interpretive phenomenological analyses to highlight the subjective understanding of the content of psychotic symptoms.

RESULTS

Interpersonal experiences were a consistent theme in participants' understanding of the content of their psychotic symptoms. Grandiose content was understood as being related to lack of relationships and helplessness, whereas harassing content was related to experiences of being abused. Commanding content was linked to emotional consequences of intrusive relationships and to distressing life events. Supportive content was viewed as a substitute for real-life persons.

CONCLUSIONS

These results support previous findings suggesting that the content of psychotic symptoms is related to interpersonal experiences. The study highlights the importance of validating the patient's own knowledge and interpretations of symptoms.

A Philosophical Perspective on the Relation between Cortical Midline Structures and the Self

In recent years there has been increasing evidence that an area in the brain called the cortical midline structures (CMSs) is implicated in what has been termed self-related processing. This article will discuss recent evidence for the relation between CMS and self-consciousness in light of several important philosophical distinctions. First, we should distinguish between being a self (i.e., being a subject of conscious experience) and being aware of being a self (i.e., being able to think about oneself as such). While the former consists in having a first-person perspective on the world, the latter requires the ability to explicitly represent one's own perspective as such. Further, we should distinguish between being aware of oneself "as subject" and being aware of oneself "as object." The focus of existing studies investigating the relation between CMS and self has been predominantly on the ability to think about oneself (and in particular thinking of oneself "as object"), while the more basic aspects involved in being a self have been neglected. However, it is important to widen the scope of the cognitive neuroscience to include the latter, not least because this might have important implications for a better understanding of disorders of the self, such as those involved in schizophrenia. In order to do so, cognitive neuroscience should work together with philosophy, including phenomenology. Second, we need to distinguish between personal and subpersonal level explanations. It will be argued that although it is important to respect this distinction, in principle, some subpersonal facts can enter into constitutive conditions of personal-level phenomena. However, in order for this to be possible, one needs both careful conceptual analysis and knowledge about relevant cognitive mechanisms.

A Philosophical Perspective on the Relation between Cortical Midline Structures and the Self

In recent years there has been increasing evidence that an area in the brain called the cortical midline structures (CMSs) is implicated in what has been termed self-related processing. This article will discuss recent evidence for the relation between CMS and self-consciousness in light of several important philosophical distinctions. First, we should distinguish between being a self (i.e., being a subject of conscious experience) and being aware of being a self (i.e., being able to think about oneself as such). While the former consists in having a first-person perspective on the world, the latter requires the ability to explicitly represent one's own perspective as such. Further, we should distinguish between being aware of oneself "as subject" and being aware of oneself "as object." The focus of existing studies investigating the relation between CMS and self has been predominantly on the ability to think about oneself (and in particular thinking of oneself "as object"), while the more basic aspects involved in being a self have been neglected. However, it is important to widen the scope of the cognitive neuroscience to include the latter, not least because this might have important implications for a better understanding of disorders of the self, such as those involved in schizophrenia. In order to do so, cognitive neuroscience should work together with philosophy, including phenomenology. Second, we need to distinguish between personal and subpersonal level explanations. It will be argued that although it is important to respect this distinction, in principle, some subpersonal facts can enter into constitutive conditions of personal-level phenomena. However, in order for this to be possible, one needs both careful conceptual analysis and knowledge about relevant cognitive mechanisms.