Self-Disorder in Schizophrenia: A Revised View (2. Theoretical Revision—Hyperreflexivity)

Abstract

A growing body of research supports the role of self-disorders as core phenotypic features of schizophrenia-spectrum conditions. Self-disorders comprise various alterations of conscious experience whose theoretical understanding continues to present a challenge. This is the second of two articles that aim to clarify the nature of self-disorders in schizophrenia by considering the currently most influential, phenomenological model of schizophrenia: the basic-self-disturbance or ipseity-disorder model (IDM). The previous paper (article 1) presented a state-of-the-art overview of this model and critically assessed its descriptive adequacy with respect to the clinical heterogeneity and variability of the alterations in self- and world-awareness characteristic of schizophrenia. This paper (article 2) proposes a theoretical revision by considering how hyperreflexivity might form the crucial common thread or generating factor that unifies the heterogeneous, and sometimes even contradictory features of schizophrenic self-disorders. We outline implications of our revised model (IDMrevised) for explanatory research, therapeutic practice, and our general understanding of the abnormalities in question.

Introduction

In our first article, we drew attention to the substantial heterogeneity and variability that characterize self-disorders in schizophrenia. We showed that alterations of self-experience can involve not only the oft-noted diminished self-presence in which patients lose the sense of being the subject or agent of their own experiences or actions, but also increased self-presence, as when patients feel they are the sole constituting witness, central figure, or prime target of all that occurs. We noted as well that the field of awareness—the lived world of objects, people, and situations—can show up in opposite ways: either as lacking organization, as seeming fragmented, random, and uncertain (decreased “grip” or “hold”); but also as hyper-organized or hyper-determined, often in a typically grandiose/paranoid manner, such that nothing seems accidental and everything appears “just so” or as somehow oriented toward or referring to the patient himself (increased “grip” or “hold”).

These contradictory aspects may not only succeed each other but can sometimes even co-exist. Their prominence clearly requires revision of the current self-disturbance or ipseity-disturbance model (IDM),^1–3 which specifies only diminished self-presence while also conceiving “disturbed grip” only as diminished grip. In article 1, we suggested the broader notions of altered self-presence and altered grip/hold, aimed at recognizing that both these dimensions of awareness can vary toward either diminishment or exaggeration, and that such variation may occur across subgroups of patients or phases of illness, but also as more moment-to-moment dynamic shifts and/or combinations at the individual-patient level.

In this second article, our aim is to go beyond these more descriptive issues by focusing on the theoretical question of how a revised IDM-model can account for these diverse manifestations. According to the revised model we will propose, it is preferable to focus on what the different manifestations of schizophrenic self-disorders may have in common rather than on what they purportedly lack. More precisely, we will argue that what the diverse expressions of schizophrenic self-disorders share is not best conceived as the absence of something that, supposedly, is constantly present in normal or non-schizophrenic forms of experience—namely, minimal self or self-presence. The shared factor is better conceived as the presence of something abnormal, namely, hyperreflexivity, which involves distinct forms of alienation, detachment, inwardness, and passivization. The self-disturbance model should be re-configured around the concept of hyperreflexivity.

We will argue for this in two main ways. In the next section, we note difficulties inherent to the concept of minimal or basic-self as well as in its application to schizophrenic self-disorders. Here we include a brief review of alternative proposals regarding the presumed essence of self-disorders. In the next several sections, we explain how hyperreflexivity could serve as a central common thread or generating factor able to unify—and in a sense, to explain⁴—the phenomenologically heterogeneous, and sometimes even contradictory, features of schizophrenic self-disorders. In a final section, we discuss research and clinical implications of our proposal.

Self-Disorders as Disorders of “Minimal Self”: A Critical Overview

In our previous article, we noted how alterations of self-experience in schizophrenia may take on various forms and qualities. Beyond this heterogeneity and variability, a more general challenge concerns how such alterations should best be conceived—comprising questions regarding what kind, level, or aspect of “self” is affected in self-disorders; in what sense it is possible for core “selfhood” to be considered disturbed; and whether a felt sense of self actually is a (necessary or regular) feature of ordinary experience (for reviews, see^5,6; for various proposals, see^6–10). Here we provide a brief overview of these debates.

A first issue concerns the seeming contradiction between the supposedly “essential” or “universal” nature of minimal self in human consciousness and its proposed alteration or disturbance in schizophrenic self-disorders. As discussed (cf. article 1), the IDM’s concept of minimal self refers not to some contingent quality that only some experiences would possess, but rather, to a structural dimension of consciousness that is considered a necessary or essential feature of how all experiences are given to a subject—what phenomenological philosopher Zahavi describes as a “first-personal character” or “what-it-is-like-for-me-ness.”^11,12

On this conception, all human experience is intrinsically—and indeed necessarily—characterized by first-personal givenness and an accompanying sense of mineness. One may wonder, however, how this supposedly inalienable character of minimal self could be consistent with the IDM’s account of self-disorders. How, or in what sense, could self-disorders involve a disturbance of minimal self if the latter is also assumed to be necessarily preserved throughout subjective life, indeed to persist as the necessary condition of consciousness itself?

Several responses to this problem have been offered.

One response⁷ consists of arguing that self-disorders do still involve a disturbance at the level of minimal self, but that the latter would somehow be merely “eroded” or “diminished” instead of being entirely absent. This solution can seem rather ad hoc (and in fact was proposed only after problems with the original model were noted). It would seem, in any case, that such a dimensional or quantitative understanding of mineness/for-me-ness runs counter to how minimal self is actually defined and understood in the phenomenological literature (see^11,12; cf. article 1). There the “mineness” of experience is not established by reference to feelings of greater or lesser intensity but argued for as a logical necessity; and it is difficult to see how it could allow of being conceived in terms of degrees. As Henriksen et al⁷ point out, even for patients with severe self-disorders, there is not (and on theoretical grounds, could not be) any relevant doubt about who is experiencing their symptoms. “[E]ven the pathological experiences under consideration,” writes Zahavi,¹¹ “retain their mineness and for-me-ness,” their “first-personal character.”

Another common strategy to address this problem has been to introduce a finer phenomenological distinction regarding the particular kind of “mineness” that is supposedly eroded or disturbed in schizophrenic self-disorders. While various proposals exist (eg,^13,14), the most prominent distinguishes between the mineness of “ownership” vs of “agency,” and interprets self-disorders as lacking agency while preserving ownership.⁶

The main problem with this account is that many of our ordinary or somewhat obsessional thoughts also come unbidden and without a sense of agency, simply crossing one’s mind, and may even be experienced as imposed and intrusive, yet do not carry the sense or quality of alienation as found in self-disorders.¹⁵ There is also the fact that schizophrenic loss-of-self can pertain not only to such activities as thinking or moving one’s arm—which do have an at least potentially agentic quality—but also to states and feelings that would normally be passively enjoyed or endured, such as emotions and sensations: What is altered in these latter experiences would seem to pertain to possession rather than to agency.

It should be noted, as well, that even the underlying assumption—the idea that a pre-reflective sense of self necessarily imbues ordinary conscious experience—is itself not uncontested.^16–18

Some theorists^18,19 have, in fact, argued that pre-reflective experience is often and perhaps typically transparent and impersonal, devoid of any form of self-awareness—as for example, when we are fully immersed and unreflectively engaged in activities. Still others²⁰ propose a more open view regarding pre-reflective consciousness, allowing for different shades or degrees of self-awareness in diverse situations or activities (eg, contrast the self-aware quality of social anxiety with the mindless absorption of the long-distance driver). Both views (whether emphasizing the supposed transparency or the supposed heterogeneity of normal self-experience) would seem inconsistent with the notion that schizophrenic self-disorders involve loss of some form of self-awareness presumed to be ubiquitous in non-schizophrenic forms of consciousness.

Hyperreflexivity as the Central Factor

We see, then, that there are problems with the notion of diminished minimal self as currently formulated. Though clearly an important symptom, it is not a constant one nor can it serve as a defining feature of schizophrenia. This is due not only to the importance of antithetical forms of exaggerated self-presence or “for-me-ness” (cf. article 1), but also (as just noted) to conceptual difficulties inherent in adapting a supposedly universal or transcendental notion to capture empirical variations on the psychological plane.

One may speak of alterations or anomalies of self-presence as key factors, but only so long as one recognizes that these disturbances can deviate in opposite, and perhaps paradoxical, directions (ie, not always or only toward diminishment). Philosophers discuss whether a truly thin notion of “core self” or minimal self-presence should be considered a sine-qua-non either of subjectivity or phenomenal consciousness itself, or of normal or ordinary consciousness.^7,11,16–22 Here we take no position on these vexed questions. Our focus is on comparative and empirical issues concerning variations of felt self-presence that might be discernable across diverse psychiatric conditions or between distinct kinds of human experience. For us, the key opposition would not be between a (presumably normal and constant) presence of self-presence versus its (supposed) absence or diminishment in schizophrenia, but rather: between more normal forms of pre-reflective immersion and absorption, however, these be understood (that is: whether as involving minimal self or not), versus hyperreflexive experiences involving altered self-presence.

The considerable heterogeneity of schizophrenic symptoms (together with their waxing and waning over time) has long been recognized, and currently fuels skepticism about the validity of “schizophrenia” as a disease entity or distinct syndrome.²³ Our own emphasis on opposite and even paradoxical aspects could contribute to such doubts. “Schizophrenia” does, however, have a long history, and there are reasons to consider it a valid and necessary category.²⁴ Like nearly all psychiatric diagnoses, schizophrenia is unlikely to be a true “disease entity,” with a unifying or singular cause and course; rather it is a syndrome comprising a diverse set of co-occurring features. But this does not mean we must forego all further explanation, limiting ourselves to listing co-occurring symptoms and signs. We agree with Karl Jaspers’ view of schizophrenia as a particularly mysterious yet indispensable category, and as one in which alterations of self-experience have a central importance (Jaspers spoke of abnormalities of the “Cogito”).²⁵

The IDM is one attempt to clarify and account for the unity of this condition; it describes a number of aspects that are intimately inter-related in various ways. We will now suggest that a component of the IDM—hyperreflexivity—may be the best candidate for bringing the disparate features of the syndrome together by showing their mutual implications and understandable interactions. Hyperreflexivity can be understood as what Eugene Minkowski²⁶ termed a trouble générateur: namely, a shared or unifying theme that permeates all the major symptoms as well as an originating process, an orientation or existential mode that contributes to development of these same symptoms: see figure 1B.

Fig. 1.

Ipseity-Disorder Model (IDM) and Ipseity-Disorder Model Revised (IDMRevised)

Hyperreflexivity’s congruence with both diminishment and increase of both self-presence and grip—and with the paradox of their co-occurrence—offers a way of understanding what can otherwise seem the strange or even inconceivable experiences that can occur. We shall argue that such an approach is congruent as well with the agentic ambiguities of schizophrenia,²⁷ ie, with its distinctive combination of quasi-intentional with passively endured factors (of “act and affliction”²⁸), and with the temporal variability of symptoms^29,30 that this combination may help to explain. As we shall see, such an approach locates the essence of schizophrenia not as diminishment or loss but as a heightening of the paradoxical heart of human subjectivity itself: the potential for reflexive self-awareness and self-distancing.

Hyperreflexivity: Definition and Historical Antecedents

Hyperreflexivity Defined

Hyperreflexivity can be defined as a rendering-explicit of aspects of experience that are normally transparent or implicit, as a bringing-to-the-fore what might otherwise have remained in the background of experience. It obviously implies a kind of inward-turning but also an extrusion, an alienation of that which is taken as the object of attention.^28,31 Like most words applied to consciousness or subjective life, “reflexive” is ambiguous. Here it will refer to a condition in which something is directed or turned back upon itself, and this should be understood in an inclusive sense. The “reflexivity” in “hyperreflexivity” refers not only to volitional, intellectual, metacognitive, or reflective forms of self-consciousness (these might be termed hyper-reflective hyperreflexivity), but also to a more passive undergoing or “suffering” of more spontaneous anomalies of consciousness and attentional or perceptual focus (termed “operative hyperreflexivity”)—as when a patient finds herself noticing, say, kinesthetic or proprioceptive sensations in her elbow or eye sockets, or somehow “hearing” the inner speech that would normally serve as the unnoticed medium of her thinking. The operative-vs-reflective distinction should be understood, in any case, more as a continuum than a dichotomy.

Historical Antecedents

The relevance of such inwardness and associated alienation has long been recognized in classic psychiatric accounts of schizophrenia that are attuned to the subjective dimension. The importance of inwardness is already evident in Eugen Bleuler’s notion of “autism,”³² which refers to the turning-away from the external and social world that he viewed as a defining symptom of schizophrenia.³³ Both Eugene Minkowski’s “loss of vital contact”²⁶ and Wolfgang Blankenburg’s “loss of natural self-evidence”³⁴ (of the sense of obviousness or the taken-for-granted) reflect this turning inward. Together they capture the accompanying alterations of external and social reality (heightened alienation, devitalization, derealization; a sense of things being uncertain and arbitrary) that prevail, often giving rise to metaphysical questioning and “existential reorientations.”^35,i

The hyperreflexive aspect is perhaps clearest in Klaus Conrad’s influential account of early schizophrenic symptoms, which he describes as involving a two-faced alteration, simultaneous and complementary, in the experience of both world and self.³⁶ These are first, the Apophany: a heightened awareness of uncanny meaningfulness or significance (the term derives from the Greek for “to become manifest”), and second, Anastrophe: a “stepping-back” from normal absorbed experience that Conrad describes as a turning-inward, auto-observation, “permanent consciousness,” or “spasm of reflexion” that suppresses one’s normal and spontaneous world-orientation and “living toward the future.”

The Japanese psychiatrists Kimura Bin³⁷ and Nagai Mari³⁸ describe a kind of constant and involuntary “self-witnessing” as the key feature. Their subtle but difficult account of self-witnessing brings out the inherently paradoxical aspect of schizophrenic selfhood, involving both a heightened self-presence and a simultaneous sense of an alien subjectivity within—and even, the achieving of heightened self-presence only at the cost of a certain alienation from one’s immediate subjectivity. Kimura and Nagai describe the kind of self-consciousness found in schizophrenia as unusual insofar as the consciousness that is somehow watched by itself does not thereby lose its quality as consciousness or as a gazing upon the world (ie, its awareness of a certain “for-me-ness” of its own experience). Such paradoxical forms can hardly be captured by a simple notion of diminished self-presence or minimal self, since they incorporate the increased (albeit paradoxical) self-presence that is inherent in a more acute experience of oneself as a knower.

The term “hyperreflexivity” was introduced through discussion of the myriad parallels between classically schizophrenic experience and expression and that typical of the modernist and postmodernist art, literature, and thought of the 20th century—ie, of artists (and movements) who turned the normally tacit foundations of both art and experience into the main subject of their work.²⁸ Such artists and movements engendered all manner of conceptual and experiential contradictions—and did so by taking subjectivity or mental life as both the prime object of attention and the “sovereign subject” or constituting center of all that exists (as what Foucault termed the “empirico-transcendental doublet”³⁹). Such contradictions are indeed “paradoxes of the reflexive.”²⁸ The parallels between madness and modernism can serve to illuminate schizophrenic phenomena that are too readily dismissed as demented, regressed, or simply incomprehensible, but that, in fact, demonstrate the peculiar, and often paradoxical, patterns inherent in such inwardness, alienation, and reflexivity.^28,40,41

Let us return to the experiential abnormalities described in our first article, but considering them now in light of “hyperreflexivity.” We consider, first, manifestations of exaggerated self-presence—whose association with hyperreflexivity might seem particularly obvious. Then we consider diminished self-presence before turning to various paradoxical manifestations.

Hyperreflexivity and Exaggerated Self-Presence

The hyperreflexive aspect of exaggerated self-presence is, perhaps, almost too obvious to require elaboration. It would seem that exaggerated self-presence just is a heightened awareness of one’s own being aware. It is, after all, a bringing-to-the-fore of something that would normally be taken-for-granted and thereby recede to the background, or, perhaps, would not be registered in consciousness at all—ie, the sheer fact of existing as, or of having, a field of conscious awareness (and thus: of the “for-me-ness” of the experienced world).

Derealization and Exaggerated Self-Presence:

Patient complaints regarding the fraudulence, flimsiness, or ephemeral quality of experiential objects—very common in schizophrenia^42,43—may reflect how the world can seem derealized in the presence of this hyperreflexive self-awareness of awareness as such: “I see things devoid of substance [ . . . ] what I see is only a play, a Punch and Judy show; it is clumsy, vulgar, unpleasant and, above all, false; it doesn’t really exist.”⁴⁴ “There is no reason for believing in the existence of an unobservable like an external world, and therefore my mind, cluttered with surprisingly uncooperative images, is my only reality.”⁴⁵

Here the “for-me-ness” seems to be exacerbated and extended, not diminished: A person who experiences even real-world objects, persons, or events as lacking a certain independence and solid reality may be hyperaware of her own consciousness as the (constituting) medium of experience, and therefore of objects in the external world as having what might be termed a “coefficient of subjectivity.”⁴⁶

Increased Grip and Exaggerated Self-Presence

Exaggerated for-me-ness seems relevant as well for exaggerated grip, whether in what we have described (in Article 1) as its mystical or its ontologically paranoid form. In the mystical case, a heightened sense of coherence and salience evokes feelings of higher unity or mystical wholeness, such that patients feel directly aligned with ultimate aspects of reality that may have previously remained hidden.^47,48 Here there seems a homogenization and effacement of boundaries: the significance of mind-world or subject-object distinctions recedes in the presence of a hyperreflexive awareness that renders all things quasi-subjectivized and thereby equivalent.

In the paranoid case, the sense of oneself as the conscious center of things grounds the feeling that other conscious centers must be attending to oneself as the ultimate centerpoint and therefore as the target of greatest interest. This hyperreflexive interpretation of paranoia may also account for its often “ontological” character in schizophrenia (cf. article 1), ie, the fact that such paranoia is often not limited to particular persons or entities (as would be the case in, eg, delusional disorders),⁴⁹ but tends to extend to the whole of reality, eg, as involving impersonal gazes or cameras that possess a ubiquitous or allover mode of presence, both internal and external. One patient is “examined throughout my life—secret cameras and microphones whirring in my head.”⁵⁰ “There was something there,” said another, “beneath me, behind me, between and above me. Everywhere and always.”⁴²

The prominence of hyperreflexivity (though not the term) is essential to the French psychiatrist Henri Grivois’⁵¹ account of schizophrenia as being grounded, in its origin and essence, in the patient’s experience of his own centrality in the universe (“centration”) and of everything being somehow concerned with or directed toward him (“concernement”)—as discussed in our previous article. And these, in turn, could obviously account for what, since Bleuler, have been recognized as the most common delusions in schizophrenia: those involving a sense of grandiosity or of persecution—delusions that, in their specifically schizophrenic form, appear to be grounded in a fundamental alteration in the way in which self and reality-in-general are being experienced.ⁱⁱ

Hyperreflexivity and Loss-of-self

Experiences of diminished self-presence may seem, at first, to be antithetical to all that has just been described, yet they too can be bound up with hyperreflexivity.

One route is already elaborated in the IDM^1,2 and earlier in Sass’s Madness and Modernism²⁸: a hyperreflexive focusing or concentration on aspects of experience that would normally be lived through in an implicit manner—and would thereby serve as the medium of a sense of self—can result in these dimensions of experience being objectified, alienated, or reified. (This may affect, eg, the inner speech supportive of thinking or the kinesthetic and proprioceptive sensations of the body.) In the current IDM this is described as undermining a supposedly normal and constant sense of implicit self-presence (“minimal self”). It can also be thought of as disrupting the spontaneous flow of absorbed experience: as inserting self-related stimuli into what might otherwise have been a transparent, world-directed, or meaning-directed flow.²²

In accord with either interpretation, the patient may well be expected to complain of a certain “loss of self”—referring thereby either to a loss of implicit self-presence that would normally be present, or simply to a disappearance of a familiar kind of engaged spontaneity. “You’re on automatic pilot and you’re an observer,” reported one patient. “You’re doing all kinds of stuff but it’s like you’re not really present, as if you’re observing everything from your own perspective. When you’re observing, you participate less.”⁴²

Some such experiences of loss-of-self may result from operative hyperreflexivity, in which disruptive sensations seem, so to speak, to pop out in an automatic or non-volitional fashion and interrupt more spontaneous or habitual modes of awareness and action. Others may involve more reflective forms of hyperreflexivity, in which self-directed attention would have a more secondary as well as a partially volitional quality. The patient may, eg, attend in a somewhat intentional or goal-directed fashion to normally implicit sensations of which she finds herself becoming aware (or to other kinds of abnormal perceptual experiences felt as unusual),ⁱⁱⁱ perhaps in order to monitor or somehow control their disruptive effect—even though (as noted above) this very attentiveness is liable to exacerbate the very alienation or abnormality she is attempting to control.

Something like this hyperreflexive progression has been documented in longitudinal studies regarding the development of schizophrenic “first-rank symptoms” from the initial and underlying subjective phenomena known as “basic symptoms.”⁵² The symptom sequence begins with a kind of “basal irritation,”⁵³ a disconcerting awareness of alterations in one’s experience of perceiving, thinking, or the body, often involving sensations that would normally have remained in the experiential background (a kind of operative hyperreflexivity). Patients who eventually developed symptoms involving loss of bodily possession, for instance, had earlier experiences of “irritating disturbances of bodily feelings or cenesthesias,” such as electrical or migrating sensations or subtle feelings of enlargement or diminishment of body parts.⁵³ Over time such awareness becomes increasingly acute, inspiring subtle experiences of “somatopsychic” or “allopsychic depersonalization or derealization” that are accompanied, as well, by “complicated processes of adaptation and coping,” including “checking efforts” and attempts to give meaning or exert control over these emerging sensations (reflective hyperreflexivity)—all this typically leading eventually into classic symptoms of truly not owning one’s own thoughts, or perhaps of one’s body being influenced from without.⁵³

Here, it seems, the awareness and the experiential alterations should not be viewed as two separable things (as if the first were a mere noticing of the second). The very fact of being so aware (so focally aware) may actually alter the experiences in question through a kind of reification, a process whereby subtle background forms of awareness are made to take on the more explicit qualities of an object of focal attention—thereby manifesting what R.D. Laing aptly termed “phantom concreteness.”⁴⁶ Antonin Artaud, who suffered from schizophrenia, experienced his own facial sensations, normally lived tacitly from within, as taking the form of a “vitreous” masklike membrane that seemed to rise off from his own face.⁵⁴

It should be noted, as well, that the very act of searching for oneself can be understood as a futile and perhaps counterproductive attempt—for as various philosophers (Hume, early Sartre, and many Buddhist thinkers) have argued, there may be no self if the latter is defined as some necessary and constant object, or even as a reliable sense of presence. In such cases, in fact, it may be the very looking for something that, by its very nature, cannot actually be found, that brings on a sense or an awareness of ungrounding that would not be present in normal, ongoing experience.

Hyperreflexivity and Dualities of Disturbed Grip

The seemingly contradictory dualities of grip are no less striking and no less explicable in light of hyperreflexivity.

A hyperreflexive or self-conscious awareness of one’s own centrality can naturally generate a sense of things being organized around oneself or of being—oneself—the prime object of all awarenesses. We have considered how this may give rise to delusions of reference, the ontological paranoia of a “watcher-machine,” or the sense of nothing being random since everything is somehow organized in relation to oneself (usually the patient cannot say just how). Antithetical developments can also occur, however, given a second factor. This is the fact that withdrawal from direct and vital engagement with the external object-world—which can also be inherent in hyperreflexivity—may weaken or undermine the normal, purpose-ridden affordances that lend pattern to one’s field of awareness, thereby undermining the normal sources of organization and meaningfulness.⁵⁵

These two possibilities correspond to the classic distinction made between two main types or syndromes of schizophrenia, the “paranoid” and the “disorganized” or “hebephrenic” types. Research shows that these classic subtypes do not in fact separate out very clearly, with many patients showing both types of symptoms at different stages of their illness or even manifesting both disorganization and paranoia at the same time.⁵⁶ (Recognition of this overlapping has led to elimination of the subtype designation in the latest diagnostic system.) The common thread of hyperreflexivity can help explain how these two aspects—seemingly so opposed—might stem from a shared underlying core, from different potentialities inherent in hyperreflexive withdrawal.

Symptom and Counter-Symptom: Paradoxes of the Reflexive

It appears, then, that hyperreflexivity can capture the co-existence of symptom and counter-symptom that (as Vygotsky noted, see article 1) seems endemic to schizophrenic conditions. Diminished and heightened self-presence; loosened and tightened grip; grandiosity and paranoia: both sides of each of these dualities can be understood as manifestations of the inwardness and alienation implicit in this introversive form of existence. These two sides of a coin are sometimes combined in representative schizophrenic symptoms that capture their paradoxical complementarity—as with the influencing-machine delusion whereby the patient Natalija posits herself as both the godlike center of all that appears and as a mere machine manipulated by mysterious others.⁵⁷

A closely related duality is apparent when Schreber recounts how his paranoid sense of being watched and controlled by the “nerves” and “rays” of God was intimately related to his own quasi-divine importance as the ultimate center of reality.^58,59 It is perhaps not surprising (indeed, perhaps is inevitable) that the one who feels himself to center or anchor the world (“I have the sensation that everything turns around me” is a common schizophrenic experience³⁶), should also be the person toward whom all meanings and messages are directed, the very one whom everything concerns—as if everything orients around oneself, rather like iron filings pointing toward a magnet. In this sense centration and concernement are complementary or mutually interdependent—two sides of a coin. There may, however, be times when one or the other takes the fore, leading to oscillations between a more grandiose and a more paranoid orientation.

Here a useful analogy is that of a sniper who, peering through his gunsight, naturally senses his own centrality as the point-of-origin of what seems the all-powerful cone of awareness that splays out before his own scrutinizing eye, yet who must realize as well (all the while, or perhaps, just before pulling the trigger) that all enemy glances might seek out and potentially converge on him, thereby transforming his own sovereign viewpoint into the target of a kind of ontological “search-and-destroy” mission. This might serve as a real-world analogy for the co-occurrence (or possible oscillation) between exaggerated self-presence and all-encompassing paranoia that are two aspects (antithetical, yet also complementary) of a hyperreflexive awareness of the “for-me-ness” of the experiential world.

Two Models: “Hyperreflexivity” vs “Diminished Minimal Self”

Variability

We have noted hyperreflexivity’s compatibility with, and indeed, its ability to account for, the remarkable diversity of schizophrenic phenomena—which includes seemingly antithetical symptoms that might seem mutually exclusive. Also significant is this construct’s compatibility with the variability of symptoms, referring now to how symptoms may wax or wane over time, sometimes imposing themselves forcefully but at other times fading away.^29,30

By contrast, “diminished minimal self” suggests a persistent condition (and has indeed sometimes been understood as such)⁶⁰ that is supposedly invariant, though somewhat changeable in its expression; it refers to an underlying state of being rather than to any process that may have brought this state about. The concept has rightly been criticized for its seeming inability to account for why sense of self appears “relatively intact prior to illness onset” but then is lost, and also for how this sense could possibly be regained or reconstructed in processes of recovery.⁶¹

What hyperreflexivity describes is, by contrast, something more like an orientation, a shifting form of attention or a tendency, a propensity to adopt a distinctive kind of inward or alienated attitude that unsettles the taken-for-granted and disrupts concentration and habitual forms of spontaneous flow. Like the self-centrality it grounds, the tendency toward hyperreflexivity may be a latent vulnerability trait. It is understandable that such an attitude might develop its own inertia and persistence, becoming almost habitual, but also that it is likely to wax and wane in accord with internal moods or other states and in reaction to external events or interpersonal experiences that may be experienced as threatening or soothing⁶²—and that these shifts may occur spontaneously, as a mindset that can overtake a person yet without being entirely beyond control. Recent methodological developments in the modeling of psychopathological dynamics⁶³ may allow empirical confirmation of these ideas, eg, by studying whether temporal increases in hyperreflexive patterns are predictive for the development of psychotic symptoms, and/or whether decreased hyperreflexivity characterizes periods of remission and recovery—thereby testing a phenomenological model of the onset and development of schizophrenia-spectrum disorders that can complement and enrich current prediction approaches.⁶⁴

Persons with schizophrenia describe such variability and, with it, the possibility of having some modicum of control.²⁷ Patients do sometimes manage to quiet their voices, often by engaging in familiar forms of practical activity, like shoveling snow or washing the dishes.^65,66 They may also bring on unusual experiences through intense hyperreflexive concentration that can bring about a sense of self-alienation but also a sense of universal centrality.⁶⁷ The latter propensity—for intense concentration—may typically be described, in psychiatry, as a defect, deficiency, or weakness, but could be thought of equally well as a capacity, perhaps even a kind of talent—for as Kimura notes, persistent “simultaneous reflection” is something that normal or non-schizophrenic people do not have the ability to sustain.³⁷

Hyperreflexivity and the “Natural Attitude”

Earlier we described the apparent variability of self-presence in more standard and clearly non-schizophrenic forms of experience (eg, variations of self-presence in absorbed versus more self-aware activities or situations). What is it, we may ask, that differentiates these from the diminishment or exaggeration of self-presence characteristic of schizophrenia? Is it, for example, a matter of type or of degree? Or is it related to the specific nature of the hyperreflexivity that predominates in schizophrenia⁶⁸?

We have already suggested some differences intrinsic to the state of consciousness involved (tacit-becoming-explicit, the peculiarities of involuntary self-witnessing). There may also be quantitative differences in the intensity of the processes or in how often or long they persist, or in the degree to which the person is able to flexibly modulate forms of tacit immersion and states of reflexive consciousness. But beyond this it may be necessary to describe as well, certain limitations on how seriously such changes are taken, given what could be described as the person’s existential attitude or orientation.^iv

For most “normal” individuals, indeed for most people who are not in the schizophrenia-spectrum or currently psychotic, something like what phenomenologist Edmund Husserl termed the “natural attitude” prevails as an underlying foundation or overarching framework, and as a set of constraints, regarding reality-in-general, that persist as the underlying and unchangeable framework of waking life. This includes assumptions, normally too obvious to be spoken or thought, that preclude either of the polarized extremes to which hyperreflexivity can lead: such “urdoxa” (foundational presuppositions) as the fact that there is an external world, that other subjectivities distinct from but akin to us exist, and that one does oneself exist (though without any insistence on its being in every moment recognized from within). One may ask whether it is the fragility of a person’s grounding in this attitude and its urdoxa that makes schizophrenic hyperreflexivity possible or distinctive (for this suggestion, see^70,71): perhaps only then can a person engage in such inward, unconventional, and alienating forms of self-consciousness which can lead to extreme experiences either of loss-of-self or of its apotheosis. Or to the contrary, is it that hyperreflexivity undermines the urdoxa—which, as it were, can be suspended or even dissolve under the hyperreflexive gaze? The hyperreflexivity characteristic of schizophrenia often has a “transcendental” flavor, given its tendency to “bracket” or set aside the “natural attitude” that is presupposed in normal forms of both consciousness and self-consciousness—ie, to take “subjectivity” rather than objective reality as primary. (By contrast, the natural attitude is interpersonally grounded, practically oriented, and typically realist regarding external reality⁷²).^v

These two dimensions—hyperreflexivity and lack of adherence to the natural attitude—seem in any case to be intimately related.^28,47,74,75 Together they seem to capture, if not the “essence” (which may not exist) then at least the distinctive signature of the diverse yet real unity, of that nest of paradoxes—human, all-too-human—that is schizophrenia.

Implications for Research and Treatment

This revision of the IDM (see figure 1A and B) has implications for both research and treatment. Consider first the issue of neural correlates and neurobiological modeling.

The Neural Plane

The minimal-self model would seem to motivate, most naturally, a search for a shared neural factor that (supposedly) would underlie the various forms of diminished minimal self-experience—almost a kind of holy grail that would index and perhaps account for this supposedly key abnormality that is assumed to lie at the core of the overtly diverse abnormalities of schizophrenic experience. Hyperreflexivity suggests an orientation that is more diverse and modest in its ambitions—and more in line with current empirical research on neurobiological correlates.

The neural correlate in question would, of course, be expected to be associated not primarily or exclusively with diminished self (nor with the hypothesis of diminished meta-cognitive awareness⁷⁶), but with the forms of self-conscious introversion captured by the hyperreflexivity notion. And these, in turn, might be expected to be heterogeneous, given the diverse ways in which “hyperreflexivity” may occur—eg, sometimes as an automatic popping-out of kinesthetic sensations that would normally have been unnoticed or suppressed (“operative hyperreflexivity,” perhaps bound up with salience dysregulation⁷⁷); sometimes as a more purposive scrutiny of background sensations or assumptions (“reflective hyperreflexivity,” perhaps bound up with hemispheric irregularities⁷⁸); and still other times as passivized withdrawal from practical activity underlying exaggerated experiences of inwardnesss and personal centrality (perhaps correlated with hyperactivation of the DMN: Default Mode Network⁷⁹) or else confusion regarding what is experienced as being “inner” versus as “outer” (perhaps correlated with unusual positive correlation of DMN with the CEN: Central Executive Network⁸⁰). Rather than a unipolar abnormality, there seems a general instability—reflected, eg, in predictive-processing studies showing weaker but also stronger “priors” in psychosis,⁸¹ or in DMN activity/connectivity being sometimes weakened but other times strengthened.⁸²

We suspect that, rather than having any single neurobiological correlate, schizophrenia needs to be appreciated in its diversity—the heterogeneity of its symptoms going along with a heterogeneity of neural correlates. The unity underlying (or coexisting with) this diversity may need to be identified on the psychological and indeed the phenomenological plane—as involving what might be termed a final common pathway, a “real or “robust pattern,”⁸³ a kind of “attractor basin”⁸⁴ (or “strange-attractor” basin⁸⁵—allowing for heterogeneity and fluctuations) whereby the different aspects of hyperreflexivity (in both operative and reflective forms) occur in a variety of both causally interacting and mutually implicatory ways.⁴ Such a basin could, of course, have a variety of more distal causal factors, both genetic and environmental.

Psychological Treatment

Implications for treatment were addressed at the end of the previous article. There we discussed the nature of heightened self-presence and tightened grip, an appreciation of which can help overcome the tendency either to find such experiences incomprehensible and alien, or else to oversimplify by viewing them as forms of secondary defense potentially subject to intellectual or cognitive refutation. It helps the clinician to appreciate the central importance of centration itself, and thus of key symptoms such as delusions of reference, grandiose delusions, and delusions of omniscience.

The most significant implications may pertain less to any specific therapeutic technique and more to an atmospheric shift.⁸⁶ This would involve overcoming a kind of epistemic injustice that is widespread and difficult to dislodge: that of condescending to the patient’s perspective by viewing it not only as inaccurate but as somehow less developed or mature than that of the non-psychotic individual.⁸⁷ Instead of viewing the seemingly contradictory claims as indicating failures of logic or regression to primitive modes, “hyperreflexivity” allows them to be, at least in some instances, appreciated as higher-level paradoxes, indeed as “paradoxes of the reflexive.”^28,39,40

Final Comment

The central role of hyperreflexivity (especially of transcendental hyperreflexivity) for understanding schizophrenia is, of course, only a hypothesis, and will need, over time, to prove its superiority to alternative hypotheses. Here we have argued that hyperreflexivity accords with the diversity of symptoms in schizophrenia; can account for its distinctive paradoxes; and offers a way of understanding its agentic ambiguities and of conceiving its variability over time. We have suggested various empirical and practical implications. We note as well that whereas diminished “minimal self” suggests a loss of the kind of self-consciousness that seems almost definitive of human nature, “hyperreflexivity” views schizophrenia squarely within the human domain—indeed, as an exaggeration of forms of awareness (involving self-consciousness and self-questioning) that are likely to be unique to our species.