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

Abstract

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

Introduction

Self-disorders (also termed anomalous self-experiences or self-disturbances) are increasingly recognized as central psychopathological features of the schizophrenia spectrum. After a period of relative neglect,¹ their importance within various domains of contemporary schizophrenia research—including diagnostic,^2,3 predictive,⁴ etiological,^5,6 and therapeutic^7,8—has currently been reestablished.

Despite this renewed research attention, the question of how self-disorders should best be conceptualized continues to present a challenge. Self-disorders—exemplified by or underlying such phenomena as thought withdrawal and broadcasting, somatic passivity experiences, and delusions of control and reference⁹—typically involve distinctive alterations of consciousness and self-experience that are notoriously difficult to comprehend.¹⁰ Current challenges include not just establishing whether self-disorders truly deviate from ordinary self-experience, but also how they deviate: ie, (1) what kind or aspect of “self” is supposedly affected, and (2) just how this particular aspect of selfhood can be considered disturbed. These questions crucially determine how self-disorders should be addressed in research, theory, and clinical practice,^6–8,10,11 yet remain subject to diverging interpretations.^12–16.

In this and the following article, our aim is to clarify the nature of self-disorders in schizophrenia-spectrum disorders by offering an overview and critical assessment followed by a significant theoretical revision of the currently most influential model of altered selfhood in schizophrenia, ie, the phenomenological basic-self-disturbance or ipseity-disorder model or IDM.^5,12,17,18

This first article is empirical and clinical in nature. We first present an overview of the current self-disturbance model; clarify the notion of selfhood it implies and its proposed alteration and pathogenic role in schizophrenia; and discuss neurocognitive and clinical implications. Next, we critically assess the descriptive adequacy of the current IDM model with respect to the clinical heterogeneity and variability of the alterations in self- and world-awareness characteristic of schizophrenia. We focus especially on (1) the nature and importance of intensified self-presence and exaggerated grip in schizophrenia; (2) the need to consider these experiences together with instances of diminished self-presence and diminished grip emphasized in the current IDM; and (3) what can seem the paradoxical implications of this dual recognition—of not only passivity experiences and diminished selfhood but also their opposites.¹⁹ This duality is a dramatic illustration of a seemingly contradictory quality highly characteristic of schizophrenia—whereby, as Vygotsky²⁰ put it, every major symptom seems to be matched by a “countersymptom, its negative double, its opposite,” by a sort of anti-world where everything appears in reverse.

The second article is more theoretical in nature. First, we mention certain ambiguities and problems inherent to the general notion of “self-presence” or “ipseity” and question the cogency of overemphasizing the role of “diminished self-presence” in schizophrenia. We then focus on the dimension of hyperreflexivity, considering how this might constitute the crucial common thread or generating factor that unifies the diverse, even mutually contradictory aspects of schizophrenic self-disorders. Finally, we outline the implications of our revised model (IDMrevised) for neurocognitive research, therapeutic practice, and our general understanding of the abnormalities in question.

The Basic-Self-Disorder or Ipseity-Disturbance Model: Overview

The special relevance of self-disorders for schizophrenia is suggested in many early accounts of schizophrenia—including those of Kraepelin, Bleuler, Jaspers, Minkowski, and others (for historical overviews^14,21,22). The idea also formed the basis for Schneider’s first-rank symptoms for diagnosing schizophrenia⁹—most involving altered self-experiences²²—and for the “basic symptoms” approach to research on the clinical development of schizophrenia.^23,24 These approaches, however, consisted largely in richly descriptive compilations of illustrative symptoms and experiences.²⁵ It is only more recently, within phenomenological psychopathology,^12,17,18 that “self-disorder” has been given a more explicit and philosophically grounded formulation in the so-called basic-self-disturbance model or ipseity-disorder model (IDM).

According to the IDM, the kind or level of selfhood that is most relevant to understanding schizophrenia is the most basic or minimal kind of self-experience. Phenomenologically considered, the minimal self (variously termed core self, basic self, and experiential self²) refers to the subjective or first-personal character of experience—its “for-me-ness.”^26,27 It captures the fact that all experiences are (presumably) given to the subject of experience in a distinctively first-personal way, ie, via a form of self-acquaintance that differs essentially from the acquaintance we have with the experiential life of others. Minimal self therefore does not refer to a separate object of experience or thought, nor to a form of self-awareness that would exist apart from our various other experiences. Instead, the self-awareness at issue is considered a structural dimension of selfhood that is inextricable from the distinct manner, or how, of experiencing. As such, it is deemed a necessary feature of experience that does not depend on language, social cognition, or rational judgment—and is in fact thought to be presupposed by such capacities.²⁷ In that sense, “minimal self” denotes the most fundamental or basic notion of selfhood which is considered to provide the foundation of (and, presumably, be a prerequisite for) more complex forms of personal, social, or narrative identity. Yet despite its formal and minimal nature, this kind of selfhood is nonetheless proposed to have a fundamental experiential reality that imbues a subject’s perceptions, actions, and thoughts with an immediate self-feeling or basic sense of mineness, first-person perspectiveness, or “for-me-ness.”

The IDM proposes that this most basic sense of self is somehow fragile or disturbed in schizophrenia, and specifies 3 main aspects of the underlying disorder. The first is “hyperreflexivity,” which involves a rendering explicit of what would normally remain tacit or implicit and comprises both non-volitional as well as more intentional dimensions.^5,28 Hyperreflexivity refers to an exaggerated self-consciousness, an inward-directed focus involving a heightened and objectifying awareness of aspects of experience that would normally be (tacitly) inhabited (eg, awareness of the act of breathing or kinesthetic sensations while walking), thereby forcing them to be experienced as if they were external objects. For example, patients may report that normally spontaneous actions like gesturing or engaging in small talk become difficult to carry out due to their excessive focus on every aspect of their performance (eg, explicit awareness of the sound of one’s own voice while speaking). The second aspect, “diminished self-presence” (previously labeled “diminished self-affection”), refers to a loss or decline in the experiential sense of existing as a coherent locus and subject of awareness and agent of one’s own actions. “Diminished self-presence” typically manifests in patient reports suggesting that the first-person immediacy of experience is somehow attenuated: “My I-feeling is diminished”; “My I is disappearing for me.”²⁹ The third, “disturbed grip or hold,” concerns accompanying world-directed alterations affecting the organization or feel of the field of awareness—alterations that perturb the tacit-focal structure (salience pattern), affordance qualities, or reality status of the world.^12,17,28 For example, everyday situations and objects may become experienced as puzzling or devoid of meaning, or the world as a whole may lose its normal quality of feeling real.

These 3 processes are seen as mutually implicatory or complementary aspects (figure 1): eg, whereas “hyperreflexivity” emphasizes that something normally tacit becomes detached, explicit, and thereby alienated, “diminished self-presence” emphasizes the obverse of the same process—the fact that what was once tacit can no longer be inhabited or enjoyed as a transparent medium of selfhood: hence, diminished self-presence. These 2 alterations of self-awareness are similarly considered to contribute to “disturbed grip or hold” by disrupting and undermining the individual’s sense of being spontaneously immersed in a shared, common-sense reality, one organized by the orienting concerns and affordances of a vital form of (minimal) selfhood.

Fig. 1.

Ipseity-disorder model.

It is further argued that this type of self-disturbance has an important role to play in differential diagnosis by distinguishing the phenomenology of schizophrenia from other psychiatric conditions.^2,18,30 The latter are either seen to involve self-related problems that are qualitatively different from minimal self-disturbance–eg, problems with continuity of personal identity in borderline personality disorders³¹ or self-worth in major depression—or to display minimal self-disturbance to a lesser degree, as in schizotypal or schizoaffective conditions.³² Empirical support comes from studies using the EASE: Examination-of-Anomalous-Self-Experience,^18,33 a semi-structured interview, and related scales.² Such research (for systematic reviews^2,3) demonstrates that basic self-disturbances are indeed more common in schizophrenia-spectrum individuals when compared with bipolar psychosis, other psychotic disorders, a mixed group of nonpsychotic disorders, and healthy controls. Detailed comparative studies using or grounded in the EASE have further explored the issue of the specificity of schizophrenic self-disorder by revealing differences but also similarities with altered self-experience not only in mania and psychotic depression³⁴—largely consistent with previous EASE research—but also, more surprisingly, with previously unstudied populations that demonstrate what appear to be some remarkably close affinities with self-alterations found in schizophrenia: namely depersonalization disorder^35,36 and panic disorder³⁷ as well as with persons engaged in radical forms of introspection.³⁸

The significance of basic self-disturbance according to the IDM goes beyond being a characteristic diagnostic feature. The IDM views basic self-disturbance as the “essential” or “core” disturbance of schizophrenia which permeates or motivates all its diverse symptoms and manifestations.^1,12,39 For example, it is suggested that delusions^40–42 and hallucinations^6,43 develop in the context of self-disturbances. Such an integrative view of schizophrenia, which focuses on grasping the basic disturbance underlying its heterogeneous clinical manifestations, contrasts with the “single-symptom” approach often adopted in current research models (eg, focusing exclusively on auditory hallucinations or paranoid delusions^44,45). It aligns with earlier attempts to capture the “core disorder” or “trouble générateur” in schizophrenia—the best-known being Bleuler re “splitting” (Spaltung) and Minkowski re “loss of vital contact” (perte de contact vital), but also Berze, Conrad, and other classic European psychiatrists.^14,46

Given this proposed significance as a potential key unifying construct in schizophrenia research, recent work has started to look for possible neurocognitive and neurobiological correlates and underlying mechanisms of basic self-disturbance. Three streams of neurocognitive and neurobiological research in psychosis have been proposed, on theoretical grounds, to show particular affinity with the IDM (for detailed discussion^47–50): aberrant salience, source-monitoring deficits, and abnormalities of default-mode network (DMN). While aberrant salience and DMN would seem predominantly linked to hyperreflexivity and disturbed grip or hold, source-monitoring deficits may be especially relevant for diminished ownership or self-presence. Neurophenomenological studies by Nelson et al.^4,51 have confirmed the relevance of source-monitoring deficits for basic self-disturbance. Furthermore, Sass et al.^5,49,50 argue that future neurocognitive research may benefit from distinguishing more clearly between primary and secondary factors of basic self-disturbance—with the former representing more foundational, enduring, trait-like features that are largely automatic and passively experienced, possibly associated with disturbed “perceptual integration” on a neurological level⁵²; and the latter, secondary factors involving more consequential, compensatory, and defensive features that may be more straightforwardly linked to source monitoring, aberrant salience, and DMN.

Finally, the IDM has important clinical implications regarding the treatment of self-disorders.^53,54 This involves viewing self-disorders not as mere false beliefs or incomprehensible phenomena, but as meaningful experiences that the IDM allows clinicians to empathically understand, at least in some respects (the meaningful understanding in question differs from most CBT and psychodynamic approaches by focusing less on the content of experience than on alterations of form or structure—eg, on altered self-world relationships rather than on the specific interpersonal themes of delusions or hallucinations).^8,55 Beyond this intersubjective recognition, the IDM suggests strategies that attempt to counteract the alienation from minimal selfhood by encouraging greater immersion or absorption in meaningful activities and non-threatening forms of interpersonal engagement. Such experiential strategies differ from the emphasis on higher-order cognition in traditional CBT approaches—which is a possibly counterproductive focus in the treatment of self-disorders given that its encouragement of “thinking about thinking” and “self-reflection” may increase hyperreflexive alienation.⁵⁴ They are, however, congruent with certain elements of so-called “third wave” CBT (eg, ACT, stimulating creative “flow” and physical activities).^7,54 To date, however, no empirical studies of phenomenologically guided treatments addressing basic self-disturbance have been published.

Critical Considerations

Despite its promising potential, recent work has exposed various problematic aspects of the IDM model. These include doubts regarding

• A: The supposed diagnostic specificity—or degree of specificity—of basic self-disturbance for the schizophrenia spectrum (see re affinities with introspectionism³⁸; Depersonalization Disorder³⁵; Panic Disorder³⁷).

• B: The alleged independence of (disturbed) minimal selfhood from interpersonal forms of experience^56,57 and from contextual events and stressors.⁵⁸

• C: The IDM’s difficult empirical application in experimental and neuroimaging research.^59,60

Here, however, we focus on more fundamental issues that specifically target the descriptive adequacy of the IDM to capture the clinical heterogeneity and variability of self-disorders.

Heightened Self-Presence

The first issue concerns the current IDM model’s exclusive emphasis on so-called “diminished self-presence” as the prototypical manifestations of basic self-disturbance in schizophrenia. Such a loss or diminished sense of self is especially prominent in Schneider’s⁹ “first-rank symptoms” (eg, thought insertion, “made” impulses and volition, etc.), which do indeed suggest apparent passivization or loss of “ownership” over thought, experience, or action: eg, “I feel that it is not me who is thinking,” “my thoughts are strange and have no respect for me,” “I have been programmed. . . . I am the beeps of the computer.”²⁹

There are, however, other alterations of self-experience—highly prominent in clinical presentations and indeed in classical descriptions of schizophrenia—that seem to entail just the opposite: not diminishment of normal core selfhood, but inflation of the ordinary boundaries of subjectivity or for-me-ness. Such “increased self-presence” is apparent in 2 highly characteristic modes of schizophrenic experience—modes worth distinguishing even though they sometimes intertwine:

Subjectivism or Quasi-Solipsism

Several central symptoms of schizophrenia and overall aspects of schizophrenic experience suggest a tendency to consider and experience things as being contained within or dependent on the perspective and confines of one’s own consciousness.^61,62 For example, many of the delusions that are most typical of schizophrenia—in contrast with the more straightforwardly empirically oriented delusions that occur in other psychotic disorders^39,40—seem not to be believed by the patient in the usual sense, ie, as literal facts existing within the context of everyday common-sense reality, but rather as pertaining to a kind of subjective, solipsistic, or quasi-virtual domain kept apart from the intersubjectively shared world and often associated with so-called “double bookkeeping.”^63,64Schizophrenia patients often fail to act on their delusions in ways one would expect of beliefs held to be objectively and intersubjectively true.⁶⁵ Such delusions are frequently described by patients in a way that suggests an acute awareness of one’s own subjectivity—as when the patient experiences (and sometimes describes) his delusional experiences as being only relevant to, and exclusively accessible from, his own perspective, or as only existing before (what the famous patient Daniel Paul Schreber called) the “mind’s eye.”⁶¹ “It is by no means impossible,’ wrote Schreber “that seeing . . . is confined to my person and immediate surroundings.”⁶⁶ A similarly self-conscious, though sometimes partial or wavering⁶³ appreciation of the subjective origin or purely personal status of one’s own experiences also frequently holds for schizophrenic hallucinations.^42,67

This subjectivism or quasi-solipsism can also apply to patients’ experience of what, to others, would seem to be objectively real: Even actual objects and the external world can be experienced by the patient as somehow de-substantialized, false, or unreal (“real life has suffered a decline,” said 1 patient⁶⁸); and this derealization often involves the sense of things being somehow contained or produced by their own consciousness—as when Schreber⁶⁶ spoke of what he called “miracled-up” people, or of insects that existed only when he looked at them. The external world may even seem to be somehow altered or controlled by one’s own consciousness: “In a certain sense I already had divine properties,” said 1 patient in this regard (patient continues: “I read something about a sunny landscape and immediately the sun came out. There existed for me a kind of relation, as if I had produced it via my concentration”).⁶⁹ “Am I the sun? Who am I?” asked another.⁷⁰ Two others spoke of “the belief I share with many schizophrenics that I am real and the rest of the world unreal,”⁷¹ and of feeling that “everything from the largest to the smallest is contained in me.”⁷²

Milder derealization may also occur, as when a patient describes objects as seeming like “mere images on canvas,” “appear[ing] as through a veil,” or feeling like “mere silhouettes.”⁷³ In such experiences, common in schizophrenia,^63,74 the normal experience of reality as an autonomous and subject-independent domain—characteristic of what the phenomenological philosopher Husserl termed the “natural attitude”—seems to be undermined, not by any lack or reduced self-presence, but, to the contrary, by an excessive for-me-ness: an exaggerated self-presence or self-awareness of the role of one’s own subjectivity as the grounding of the world.

Ontological Paranoia

Paranoid delusions are common in nearly all types of psychosis (including affective psychoses and “Delusional Disorder”), but certain kinds of paranoid delusions do seem rather specific to schizophrenia.^40–42 Such paranoid delusions are not primarily concerned with the content of reality—with issues existing within the world (such as worrying that a robber is poised to attack), but with more persistent and foundational transformations in the basic coordinates of experience itself. Specifically, in what can be termed ontological paranoia,⁷⁵ there is a pervasive sense of being oneself at the center of all of reality and, as a result, of being oneself the likely or even inevitable target or object of attention toward which all messages and meanings will seem to be directed. “It feels like the universe is zoned in on me,” said 1 patient.⁷⁶

Such encompassing paranoid experience does not seem to derive primarily from some exceptional personal or empirical characteristics that might solicit persecutory attention (eg, one’s physical appearance or socio-economic status) but from an acute and incessant awareness of one’s own centrality as a conscious and knowing subject.⁷⁷ The observing others (watchers or listeners) are often felt to be focusing not on one’s physical appearance in the shared world but on one’s consciousness or subjective life. In an autobiography titled The Witnesses, 1 patient wrote: “I thought that a powerful cine-camera took a photographic record of this scene, for some such instrument was focused on me, and its effects remained for some weeks afterward. . . . A voice whispered: ‘They have taken a photograph of your mind, Thomas.’”⁷⁸

The French psychiatrist Henri Grivois⁷⁹ describes the key aspects of schizophrenic experience as “centration” and “concernement”—terms he coined to describe the often uncanny sense of being at the epicenter of the universe and of experiencing all things as somehow concerning or pertaining to oneself (a kind of for-me-ness). Grivois emphasizes the formal and ontological aspects of this sense of centrality, especially how all of experience becomes centripetally organized around and directed toward the self. Such “self-centrality” or “central polarization” is an “emblematic characteristic” of psychosis that is prominent in the so-called “basic symptoms” of schizophrenia, and empirical studies confirm its presence across all phases of the illness.⁸⁰ It seems likely to play a role in Anderssein, the prominent sense of being profoundly yet indescribably different from other people that is commonly felt by such persons.^81,82

The idea that centration and concernement could be associated with a straightforward diminished self-presence is implausible—how, after all, could a person who feels she does not exist as a conscious self, ever sense that everything somehow revolves around her, as schizophrenia patients sometimes do? What centration and concernement actually suggest is, again, a kind of exaggerated self-presence or minimal self: an intensified, often anxiety-ridden awareness of one’s own subjectivity or “for-me-ness.” We discussed above how the intensified “for-me-ness” of experience can make the world seem less real. Here we see that it can also rob the external world of any possibility of randomness or of indifference to oneself, fueling ideas of reference and the general sense that all people and events must somehow orient toward or pertain to oneself—as if all meanings and awarenesses could hardly not be aware of this awareness (one’s own) that centers and thereby dominates the experiential field.

In Sum

Both quasi-solipsism and ontological paranoia are crucial aspects of schizophrenia that are frequently present (during both onset and later stages of psychosis^75,80), long recognized,^9,69,79 and clinically significant. Over the years, many theorists, including Bleuler⁸³ and Jaspers⁷⁰ have recognized 2 classic types of delusion, grandiose and persecutory, often interpreting one or the other type as more basic and as inspiring the other type. We prefer to emphasize a shared factor: the existence, in both cases, of an excessively acute (albeit also potentially paradoxical) awareness of one’s own subjectivity, self-awareness, or self-presence—an excess of self-centrality no less significant than is the loss or deficiency of self-presence emphasized by the current IDM.

Paradoxical Combinations: Diminished and Expanded Self-Presence

A further challenge for the IDM’s notion of diminished self-presence is the fact that many patients seem to shift or waver between the poles of “diminished” versus “expanded” selfhood, or even—paradoxically—to maintain both positions at the same moment. Both Bleuler⁸³ and Jaspers⁷⁰ noted a tendency for quasi-solipsistic feelings of grandiosity, omniscience, and centrality to be mixed with concurrent yet antithetical feelings of persecution, powerlessness, and inferiority: as when a patient who declares himself omnipotent and ruler of the universe may also say he does not exist, or that his body or thoughts are under alien control or are purely mechanical in nature.¹⁹ The patient is “sometimes an automaton moved by the agency of persons, . . . at others, the Emperor of the whole world,” wrote the alienist John Haslam in 1810, in what is widely regarded as the first psychiatric description of a person with schizophrenia.⁸⁴

In another classic case, of the “influencing machine” delusion,⁸⁵ all that the patient experienced seemed to exist only in her own field of awareness, but she also experienced herself as a machine manipulated by mysterious men. In such cases, these apparently opposed and indeed, seemingly incommensurable tendencies (of being a sort of divine center, yet also of being targeted and controlled) were somehow deeply interconnected. Delusions (or quasi-delusions) about cameras or videocameras—common in schizophrenia^86,87—illustrate the point. Often there seems to be the sense of being a kind of godlike camera that centers and indeed constitutes the visual world, but also of being somehow at a remove from one’s own consciousness, which is being filmed from without. “I was myself a camera,” said 1 patient.⁸⁸ “The views of people that I obtained through my own eyes were being recorded elsewhere to make some kind of three-dimensional film.”

A number of philosophically informed first-person accounts of altered self in schizophrenia emphasize that such self/non-self-paradoxes (also paradoxes of meaningfulness/meaninglessness; see below) may lie at the core of the condition, contributing to its paradigmatically bizarre or incomprehensible character.^89,90 In this vein, Humpston⁹⁰ describes schizophrenia as “a paradoxical condition [experienced] from within the paradox itself,” “lived viscerally through a prism of contradictions, tautologies and dilemmas.” But as with exaggerated self-presence, it is difficult to see how the IDM’s current focus on diminished self-presence can capture such paradoxical experiential combinations—in which loss of ownership over one’s immediate subjectivity alternates or even coexists with the grandiose sense of being the all-encompassing center of the All.

Let us now turn from self to world, by taking up the third dimension of the IDM model: “disturbed grip or hold” on the cognitive or perceptual field of awareness.

Disturbed Grip or Hold

Consistent with its emphasis on “diminished self-presence” in schizophrenic self-disorder (and despite using the more general phrase “disturbed grip”), the current IDM has privileged the diminished forms of “disturbed grip or hold,” namely, varieties of world experience in which the oriented and organized quality of the normal experiential world is lessened or destabilized. “Diminished self-presence” implies a weakening of basic self-experience, including its role as a meaningful point of orientation imbued with needs, desires, and purposes that would normally ground one’s experiencing of the affordances of a coherent and significant world.^11,91

“Diminished grip or hold” certainly captures some types of reality-experience in schizophrenia that would seem closely related—including loss of common sense or diminished “natural self-evidence,” release of decontextualized perceptual saliences, overall sense of strangeness and perplexity, of unpredictability or constant surprise, along with an associated subjective withdrawal that typically mark the early stages of psychosis onset.^64,74,92,93 Elsewhere we have considered these important anomalies in detail.⁹⁴ There are, however, other forms of reality experience, especially (though not exclusively) prominent in early stages of schizophrenia, that suggest feelings of hyper-organization: experiences of increased rather than diminished coherence and meaningfulness of the world,^42,64,89 as when everything seems somehow predetermined and self-referential, often associated with a sense of absolute certitude or extraordinary insight.

Consider, eg, what has been termed “hyperreal reality-experience,”^64,89 a central aspect of “delusional mood^”41,70 in which things and events seem permeated by an overall sense of necessity, compulsion, and heightened meaningfulness. In such moments, everything takes on a deeper significance and feeling of necessity—as if nothing merely happened and mere coincidence or pure contingency were no longer an experiential possibility (what Minkowski⁹⁵ terms “loss of contingency”). “During a psychosis, it is all so intense, all so utterly life-like”, said 1 patient. “You know that everything is meant to be.”⁶⁴ The heightened coherence and salience are sometimes felt as blissful states of higher unity or mystical wholeness in which patients feel directly aligned with ultimate ontological aspects of the cosmos that would normally remain hidden or unnoticed.^89,96 It may, however, also accompany the ontological paranoia already mentioned—the oppressive sense of the world of hidden meanings always pointing or referring to oneself.^69,79 These 2 modes may differ in their prevailing mood: 1 positively toned, the other mostly negative. What is shared is an overall aura of increased meaning and organization of the field of awareness that is not captured by the current IDM’s exclusive emphasis on diminished grip or hold.

Moreover, similar to altered “self-presence” (see above), these seemingly antithetical forms of “diminished” and “increased” grip or hold are not mutually exclusive. Paradoxically enough, they can combine and co-occur—which is why experienced reality in schizophrenia can successively or even simultaneously appear as both less and more meaningful, less and more organized, less and more “real.”^64,89

First-person accounts of altered reality-experience in schizophrenia^64,72,89 often describe such ambiguity—by emphasizing, eg, that estrangement from common-sense reality (suggesting “diminished grip/hold”) may enable a more perspicuous grasp of a deeper, more truthful kind of ontological dimension (“increased grip”). One patient seems to have evoked this complex intertwining of opposites in describing his delusional mode of perception: “one can be much clearer about the relatedness of things, because one can overlook the factuality of things.”⁹⁷ Another: “It is in a sense paradoxical that nothing can be more real than the experience of unreality.”⁷² The current IDM’s emphasis on diminished grip or hold (and on an associated diminishment of self-presence) ignores the fact that such opposing perspectives on reality can overlap and co-exist. Two classical psychopathologists whose views tend sometimes to be equated, actually differ on this issue: Whereas Matussek’s⁹⁷ Gestalt-inspired account focuses almost entirely on the loss of “firm perceptual cohesion” (loosened grip), Klaus Conrad⁶⁹ emphasizes the heightening of both self-presence and self-directed meaningfulness (tightened grip).

Revision and Implications

We have discussed several phenomena that are neglected in the current IDM account: (1) forms of exaggerated or increased self-presence (eg, in schizophrenic subjectivism/quasi-solipsism and ontological paranoia); (2) forms of increased grip or hold over the experiential field (eg, in forms of “hyperreal,” mystical, and paranoid experience); and (3) a paradoxical co-existence of, or dynamic shifting between, diminishment and increase in the realms both of self-presence and of grip/hold (eg, in combinations/alternations of grandiose and passivity delusions). Such experiences appear to have a primary, foundational, or core status; they occur early in the illness and persist in various forms. Although the IDM does emphasize the remarkable heterogeneity of schizophrenic symptomatology,^5,12 its neglect of these 3 features impedes its ability to appreciate the diverse and highly variable nature of the self-disordering that may occur in schizophrenia. The heterogeneity at issue may involve differences between different individual patients or subgroups of patients, but also dynamic shifts or combinations within a particular patient. All this suggests the need to theoretically revise and expand both the IDM’s descriptive account (in this article) as well as its underlying assumptions (see article 2).

Descriptive Psychopathology

On a descriptive level, a revised self-disorder model will need to postulate the broader notions of altered self-presence and altered grip/hold while recognizing that each of these distinctive alterations can move toward either diminishment or exaggeration. Such recognition avoids the common error of conflating any deviation from normalcy with deficit, diminishment, or decline (or in psychoanalysis, with “regression”). One could, of course, speak of diminished normal self-presence (ie, of self-presence in its normal forms) or of diminished normal grip, but this should not be conflated with a general diminishment of either self-presence or grip (since both increase and decrease can contribute to this deviation from normalcy). Such recognition improves the descriptive adequacy of the model and may also contribute to enhanced clinical management as well as explanatory research.

The important research using the EASE^2,3,18 does demonstrate the prominence (but not the exclusive presence) of core-self abnormalities in schizophrenia. It does not, however, illustrate primarily diminishment or loss of minimal self. While many EASE-items³³ clearly indicate diminished self-presence: eg, Diminished sense of basic self (#2.1) or Psychic depersonalization (#2.3); others suggest exaggerated self-presence: eg, Feeling of centrality (#5.2), Feeling as if the subject’s experiential field is the only extant reality (#5.3), Solipsistic grandiosity (#5.8). (Many items can be construed in either way; nearly all items are at least consistent with “hyperreflexivity” broadly conceived—including within the domains “Cognition and stream of consciousness” [#1]; “Bodily experiences” [#3]; and “Demarcation/transitivism” [#4].) The predictive and differentiating capacity of the EASE might in fact be improved by the inclusion of more items that capture exaggerated self-presence and tightened grip—such as from a sister interview schedule, the EAWE: Examination of Anomalous World Experience,⁷³ re “All-inclusive self-consciousness/Ontological ‘paranoia’” (#5.12) and “Intensified awareness of patterns or trends” (#5.10). This may help differentiating schizophrenia-spectrum disorders more clearly from, eg, depersonalization disorder, where exaggerated forms of self-presence and grip/hold seem more rare.⁹⁸

Clinical Implications

In a clinical context, acknowledging instances of increased self-presence may afford a more adequate understanding of such prominent experiences in schizophrenia as paranoid anxiety and feelings of exceptionality. The revised model allows these to be understood not in terms of (motivated) reasoning biases involving cognitive deficiencies—which is a common^99,100 yet contested^41,101 CBT-oriented explanation—but rather as generated and sustained by more fundamental experiential changes involving exaggerated self-awareness. Similarly, recognizing how reality in schizophrenia may not only be perplexing and doubtful, but also unusually meaningful and coherent, can help mental health professionals understand why patients may sometimes hold ambiguous or positive attitudes toward their symptoms,¹⁰² or why their fearful stance is seldom touched by evidence or logical argument.⁴¹ Overall, increased awareness of the sometimes paradoxical nature of self-disorder can overcome the initial sense of incomprehensibility and thereby improve the empathic alignment between patients and caregivers.^8,55 It can help both clinicians and patients understand that “altered interpersonal contact” in the schizophrenia spectrum cannot be dismissed in pure deficit terms, but involves a qualitatively distinct orientation (involving self-centrality, alienation, etc.) that “most defines the acute state of suffering of the patient.”⁸⁰

With respect to clinical strategies, our revision underscores the relevance of psychosocial treatments broadly aimed at “decentering” patients’ sense of centrality by fostering or reestablishing awareness of others and the world as fundamentally distinct from patients’ own subjective perspective. Amongst current psychotherapies, such a focus on “decentration” can be found, eg, in metacognitive approaches¹⁰³ that attempt to address and counteract centrality by stimulating patients’ capacity for self-reflection and awareness of alternative perspectives. While agreeing with this general therapeutic goal, our revision suggests that centrality is better conceived, not as metacognitive deficit or reflexive deficiency, but to the contrary, as grounded in an abnormally acute and arguably excessive self-awareness of the role of one’s own subjective perspective in the experience of the world. What seems more appropriate to counter such excessive self-awareness are embodied and enactive strategies aimed at increasing spontaneous, prereflective, and “unthinking” engagement in the everyday shared world (eg, stimulating practical and physical activity, reducing social isolation; for an overview⁷).

Implications for Research

In pathogenetic research and modeling, the revised IDM allows considering increased self-presence or increased grip/hold, and associated paranoid and grandiose orientations, not merely as secondary or defensive reactions, but as playing a more primary role in the development of schizophrenic symptoms such as delusions. Despite being familiar to many clinicians and prominent in classical psychopathological accounts,^69,70,79 self-centrality and exaggerated self-presence have been oddly neglected in pathogenetic modeling across theoretical orientations—eg, in (neuro)cognitive models as well as in phenomenological psychopathology. The general tendency has been to accord causal primacy to diminished self and diminished grip. Paranoid and grandiose developments are often treated as having a secondary, less essential, or primarily defensive status—eg, as delusional interpretations that serve primarily to explain or otherwise lend a sense of meaning to prior experiential anomalies, such as a “disturbed sense of agency”¹⁰⁴ or a “loosening of perceptual context.”⁹⁷ Despite their popularity, such accounts face empirical and conceptual challenges—including, eg, a lack of clear empirical support for reasoning biases/abnormalities in delusional patients with schizophrenia,^41,105 or the fact that developing delusions seldom possess the “feel” of reasoned conclusions or explanations.¹⁰⁶ These are challenges that the revised self-disorder model (IDMrevised) can address.

The revision encourages broadening the focus of current neurocognitive models of self-disorders. Most IDM-informed research on underlying neurocognitive mechanisms has focused its theoretical proposals^5,47–50 and empirical investigations^4,51 on clinical examples involving diminished self-presence and diminished grip/hold. The broader heterogeneity of self-disorders emphasized in this article suggests the need to reconsider to what extent these neurocognitive proposals are—or can be made—compatible with this experiential variability.

Consider, eg, that explanations of diminished self-presence typically appeal to deficits/impairments in source-monitoring^47,104,107: How, one may ask, might these square with instances of increased self-presence, which might seem to involve modes of experience (eg, quasi-solipsistic feelings of centrality) that may be characterized by excessive rather than reduced ability to monitor self-related information, or perhaps by inability to suppress such information in establishing a transparent and subject-independent experience of reality? One possibility is to conceive of normal, successful source-monitoring in terms of the ordinary attenuation or suppression of self-related aspects of experience: ie, as crucially involving the ability to process such information in an automatic, transparent, and background fashion.^108,109 On this understanding, disruptions of the normally tacit nature of source-monitoring would have dual implications: potentially entailing a heightened awareness of self-related stimuli (consistent with schizophrenic subjectivism and derealization), but also a loss of more spontaneous and immersed forms of experience and the tacit forms of normal self-presence these involve (consistent with first-rank symptoms involving passivity and detachment).

With respect to disturbed grip/hold, there have been several attempts to integrate phenomenological models with the construct of “aberrant salience”^48,110,111 and with the possibly underlying disturbances in predictive processing.^112,113 In this regard, our revision has emphasized the important phenomenological heterogeneity that underlies aberrant salience, which consists not only in loss of habitual forms of contextual perception and consequent foregrounding of disruptive fragmentary saliences,⁴⁸ but sometimes also in the increased experience of organization, determination, and overall coherence of the perceptual field—as in the all-inclusive self-referentiality of ontological paranoia. While the former kind of aberrant salience has been associated with a diminished influence of top-down predictive signaling,^51,114 the latter kind has been accorded less attention—yet may be plausibly linked to a potentially enhanced effect of top-down predictive processing and of “strong priors,” which have also been found in psychosis.¹¹⁵

Conclusion

This article presented a state-of-the-art overview and critical assessment of the phenomenological basic self or IDM of schizophrenia. We highlighted the significance of the self-disturbance construct across various domains of schizophrenia research, while pointing out several key experiences that are not adequately covered by the current IDM: namely, forms of exaggerated or increased self-presence, of increased grip/hold over the experiential field, and mixed and/or dynamic combinations of diminishment and increase in both these realms. To accommodate this additional heterogeneity/variability, we suggested the broader notions of altered self-presence and altered grip/hold and pointed out clinical and explanatory advantages of this revision.

We note, in concluding, that the substantial heterogeneity of self-disorders may seem to pose a challenge to the attempt to provide a unifying theory of schizophrenia: perhaps undermining any attempt to postulate an underlying core disorder or “trouble générateur” that could account for and unify this heterogeneous condition. In article 2, however, we will argue that the first key notion of the IDM—that of “hyperreflexivity” (defined above)—can in fact serve as a unifying factor since it can be seen to be consistent with, and even to underlie, the various manifestations that seem to be antithetical to each other, such as diminished as well as exaggerated self-presence or grip.