Abnormal Space Experiences in Persons With Schizophrenia: An Empirical Qualitative Study

Abstract

Abnormal space experience (ASE) is a common feature of schizophrenia, despite its absence from current diagnostic manuals. Phenomenological psychopathologists have investigated this experiential disturbance, but these studies were typically based on anecdotal evidence from limited clinical interactions. To better understand the nature of ASE in schizophrenia and attempt to validate previous phenomenological accounts, we conducted a qualitative study of 301 people with schizophrenia. Clinical files were analyzed by means of Consensual Qualitative Research, an inductive method for analyzing descriptions of lived experience. Our main findings can be summed up as follows: (1) ASEs are a relevant feature in schizophrenia (70.1% of patients reported at least 1 ASE). (2) ASE in schizophrenia are characterized by 5 main categories of phenomena (listed from more represented to less represented): (a) experiences of strangeness and unfamiliarity (eg “Everything appeared weird. Face distorted, world looks terrible, nasty”); (b) experiences of centrality/invasion of peripersonal space (eg “Handkerchief on scaffolding: message telling him something”); (c) alteration of the quality of things (eg “Buildings leaning down”); (d) alteration of the quality of the environment (eg “Person sitting six feet away seemed to be at an infinite distance”); and (e) itemization and perceptive salience (eg “All patients [in ward] have bright eyes”). (3) ASEs are much more frequent in acute (91.9%) than in chronic (28.15%) schizophrenia patients. Moreover, our findings further empirical support for phenomenological accounts of schizophrenia, including those developed by Jaspers, Binswanger, Minkowski, and Conrad, among others and provide the background for translational research.

Introduction

Many empirical studies of schizophrenia leave us with an impoverished view of the experiential disturbances that characterize this condition. In this article, we present the results of a qualitative study of 301 people with schizophrenia, focusing on disturbances in one core structure of their experience: lived space, ie, space as experienced, not as an objective coordinate system¹ but the meaningful, practical space of everyday life. Lived space is centered on the person and characterized by qualities such as vicinity/distance, wideness/narrowness, and connection/separation. In it, things may appear salient, significant, and attractive or meaningless and irrelevant.²

A number of studies have confirmed that experiences of space are altered for people with schizophrenia.^3–6 Building on and extending these studies, our aim is to provide a detailed description of what these spatial experiences are like and a nuanced insight into the lived world of people with schizophrenia, focusing on their experience of space, objects, and other human bodies.

Lived Space in Persons With Schizophrenia

Phenomenological studies of schizophrenia typically focus on experiential disturbances beyond current diagnostic criteria, such as disturbances of selfhood.^7,8 With the recent introduction of the Examination of Anomalous World Experience (EAWE),⁹ phenomenological psychopathologists attended to disturbances of lived space in schizophrenia.¹⁰ An exploratory study reviewing classical phenomenological literature and first-person reports provided an initial sketch of abnormal space experiences (ASE) in schizophrenia. However, as the authors say, “[o]ur approach is fairly speculative and anecdotal, and obviously needs to be corroborated by empirical research — to which it should serve as a necessary theoretical preliminary.” ^11(p133) Because our aim is to provide such an empirical investigation, we here briefly review these preliminary findings as a background for our empirical research.

The current literature suggests that ASE in schizophrenia, especially in early schizophrenia, are common but varied. Normal spatial properties, such as relative size or shape of things, can alter.¹¹ Some patients report a sense of space being infinite, stretching on forever. This is accompanied by a sense of displacement. This may manifest as an ontological focus, in which the mere existence of objects—rather than their practical significance—is what stands out.^11(p147) They may feel that they have no definite point of view upon the world—they feel displaced or out of place.^11(p135) Space may also take on an uncanny atmospheric quality, as if the space itself is threatening or foreboding or has some special (but inarticulable) meaning. Sometimes this strange atmospheric disturbance culminates in an experience of solipsism: the world depends on the very existence of the person with schizophrenia.

And this experience can apply to objects within space as well. Things may be perceived as no longer flesh-and-blood entities but mere images. Everyday utensils can lose their sense of practical significance,^2,12 have an uncanny or highly individualized meaning, or “uncanny particularity” ¹³ that one cannot fully grasp: “[e]very detail and event takes on an excruciating distinctness, specialness, and peculiarity” ^14(p52)—some definite meaning that eludes all attempts to grasp it. Space itself may be experienced as if from no particular standpoint or as having some special personal or revelatory meaning.

Materials and Methods

Materials

This is a retrospective study on clinical files of 550 consecutive patients affected by schizophrenia and affective disorders interviewed between 1979 and 1993 by J.C. (an experienced senior psychiatrist). Patients were assessed through clinical interviews in a “second opinion” program. Details of the interview process are given in Methods. Appropriate consent was obtained from all patients for the purpose of the interviews.

The study is in accordance with the ethical principles of the Declaration of Helsinki with the ethical code of the Association of Italian Psychologists¹⁵ and Legislative Decree 196/June 30, 2003 (Italian personal data protection code).¹⁶ All data were gathered prior to Italian Law 675/96 and Legislative Decree 196/03¹⁷; as these norms are not retroactive, the approval of an ethics committee does not apply.

Diagnoses, which at the time of the first interview were assigned according to the diagnostic and statistical manual of mental disorders (DSM)-III-R, were reassigned according to DSM-5. Disagreements among investigators about diagnosis were a case of exclusion. Sample extraction is detailed in figure 1 and demographic features of the final sample in Table 1. Of the original 550 patients, 301 (54.72%) were retained for subsequent qualitative analysis: 103 chronic schizophrenia patients and 198 acute schizophrenia patients. Acute schizophrenia patients had clinical exacerbation occurring in the last month confirmed by major changes in pharmacotherapy; chronic schizophrenia patients have at least 2 years of continuous duration of illness.

Fig. 1.

Sample extraction.

Table 1.

Sociodemographic features

	Partecipants schizophrenia	Schizophrenia
		Acute		Chronic
N	301	198		103
Gender: male/female	210/91	137/61		73/30
%Male	69.19%	69.76%		70.87%
Age		fi	f%	fi	f%
≤19		6	3%	3	2.9%
20–30		142	73%	83	80%
31–41		31	15%	11	10%
42–52		11	5%	5	4.1%
53–63		6	3%	1	3%
64–74		2	1%	—	—
75–85		—	—	—	—
Means		24.89		22.58
SD		7.78		8.14

In the present study, we restricted our analysis of the clinical material to subjective anomalies in one’s feelings, sensations, and perceptions arising in the domain of lived space (termed “abnormal space experience,” ASE). Our a priori definition of ASE is the following: an anomalous awareness of surrounding environment affecting its extension, distances, or perspectival properties, as well as the characteristics of things or persons.

Methods

Data were collected via a semistructured interview with open questions, adopting an interactive conversational style exploring life-time symptoms and abnormal phenomena. The aim was to extract experiential patterns of fringe experiences from self-descriptions, particularly with regard to space, time, body, and self. Interviews sought the qualitative features of experiences and to illuminate them through vivid self-descriptions rather than measure or causally explain them.

Interview questions related to abnormal fringe phenomena were always generated within the interview context and attuned with the interviewee’s personal experience and involvement. Examples of questions and prompts include “Did you ever experience a weird atmosphere, as if the others were all looking at you or things arranged around you in order to mean something to you?”; “Did you experience some strangeness in the proximity or distance of things, for instance, or in their dimensions, shape and colours?”; “Did you ever experience the environment as flat, without any point of orientation, meaningless?” The duration of the interview was approximately 90 min.

The study was retrospective on clinical records that were originally produced by taking notes during the interview. From 2009, these were digitized and subsequently reexamined for the purpose of the present research. All data contained in the original interview notes, including age, sex, handedness, IQ, number of episodes, duration of illness, major medical information (eg, brain trauma, serious physical, and neurological illness), main symptoms (eg, delusions and hallucinations), and abnormal experiences of space, time, body, and self were inserted into the digitalized database. The project, named “Life-World Project” (LWP),^18–33 a descriptive study of the lived world in which the patient actually exists, was not carried out until 30 years after data collection since no suitable qualitative methodology (consensual qualitative research, CQR) was established and manualized until recently. The LWP has two main aims: clinical (to improve diagnostic validity, reliability, and the phenomenological understanding and treatment of severe mental disorders) and ethical (as only within the realm of one’s own lifeworld can one be understood by one’s community, and only in it can one work together with them and a common, communicative surrounding be constituted).

Digitized clinical files were subsequently reexamined by two senior psychiatrists (G.S. and M.B.). All available psychopathological data (eg, delusions and hallucinations) were classified according to manual for assessment and documentation of psychopathology in psychiatry Section 4,³⁴ a comprehensive tool of psychopathological assessment including symptoms’ operational definitions.

ASE were reclassified following CQR.^35,36 Qualitative research is essential for improving the understanding of the patients’ morbid subjectivity, not constrained by fixed schemata, such as specific rating scales, bringing forth the typical feature(s) of subjective experiences in a given phenomenon. CQR is designed for in-depth descriptions of subjective phenomena while reducing the bias of the researcher’s subjectivity. We adopted CQR for the following reasons: (1) CQR is a manualized method—the existence of a handbook is essential for making a qualitative method transmissible and replicable; (2) CQR is a rigorous reflexivity practice^36,37 based on “consensus among judges” procedure allowing for better objectivity through intersubjectivity; (3) CQR does not aim to select a single-core category with a hierarchical structure because it does not aim to propose a new theory but to describe a given phenomenon in great detail. The researchers for this study were two senior psychiatrists (G.S. and M.B.) and two senior psychologists (S.B. and E.B.). The external auditor was a senior psychologist (M.M.).

In the phase called “cross-analysis,” we identified common themes in ASE in order to place the central experiences within the categories. According to CQR, a typical category must include more than half of the participants. Each category (eg “strangeness and unfamiliarity”) may include more subcategories (eg, “weird atmosphere”). More details can be found in Stanghellini et al.^18,22

Results

About 70.1% (211 out of 301) of patients reported at least one ASE. ASE are more frequent in acute (182/198, 91.9%) than in chronic schizophrenia patients (29/103, 28.15%). Thirty-four patients experienced ASEs in different categories; the most frequent coexistence was between strangeness and unfamiliarity and centrality/invasion of peripersonal space. Thirty-one patients reported more than one ASE in the same category.

Our main findings can be summed up as follows: (1) ASEs are a relevant feature in schizophrenia. (2) ASEs in schizophrenia are characterized by 5 main categories of phenomena: (a) experiences of strangeness and unfamiliarity; (b) experiences of centrality/invasion of peripersonal space; (c) alteration of the quality of things; (d) alteration of the quality of the environment; and (e) itemization and perceptive salience. (3) ASE in acute and chronic schizophrenia show different profiles (see table 2).

Table 2.

Abnormal space experiences (ASEs) in persons with schizophrenia: N of reported ASEs and N of patients reporting ASEs

Domain	Categories	Subcategories	Acute		Chronic
			N of experiences	N of patients	N of experiences	N of patients
ASEs: N = 246			215	182	31	29
			(87.4%)	(91.9%)	(12.6%)	(28.15%)
	Strangeness and unfamiliarity	Weird atmosphere	35	27	5	5
			(16.27%)	(14.83%)	(16.11%)	(17.24%)
		Strangeness about people’s expressive properties	37	29	6	5
			(17.20%)	(15.93%)	(19.35%)	(17.24%)
	Experiences of centrality/invasion of peripersonal space		65	55	11	11
			(30.23%)	(30.21%)	(35.48%)	(37.03%)
	Alteration of quality of things	Alteration of colors	20	19	4	3
			(9.30%)	(10.43%)	(12.90%)	(10.34%)
		Alteration of geometric proprieties (dimensions and shape)	11	11	1	1
			(5.11%)	(6.04%)	(3.22%)	(3.44%)
	Alteration of the quality of the environment	Alteration of the environment extension	17	15	3	3
			(7.90%)	(8.24%)	(9.67%)	(10.34%)
		Spatial disorientation (loss and bewilderment)	9	8	1	1
			(4.18%)	(4.39%)	(3.22%)	(3.44%)
	Itemization and perceptive salience		21	18	0	0
			(9.76%)	(9.89%)

Category 1: Strangeness and Unfamiliarity (83/301; Acute: 72/198 [This Ratio Expresses the Number of Reported Experiences/Number of Patients]; Chronic: 11/103)

Things and the whole world appear unusual. Space and things lose their materiality and become spooky. An ambiguous and elusive atmosphere emerges (see table 3).

Table 3.

Categories 1 and 2

Category	Core phenomenon	Typical sentences	Subcategory
1. Strangeness and unfamiliarity (N = 83)	Things and the whole world appear strange and unfamiliar. Things seem to become different. Space and things lose their materiality and become spooky. A rarefied, ambiguous, and elusive atmosphere emerges.	“Everything appeared weird. Face distorted, world look terrible, nasty. I didn't want to live in it.” “World looks watery, strange, different.” “I live in a graveyard.”	1.1. Weird atmosphere (N = 40) Typical sentences are: “World look angelic, heavenly surroundings.” “Everything unreal.”
			1.2. Strangeness about people’s expressive properties (N = 43) Typical sentences are: “Faces look sunken, as if they're different people.” “Other people ‘toys’-almost dead and lifeless carrying out automatic movement.”
2. Experiences of centrality/invasion of peripersonal space (N = 76)	Patients feel they are uncomfortably center-stage. Other people look at them, spy on them, send them messages, or hide something for them. Things are directed to them meaning something personal.	“Cat jumping card board box signified a spiritual change in her”. “TV, radio, people on buses refer to him”.

Typical sentences: “Everything appeared weird. Face distorted, world looks terrible, nasty,” “World looks watery, strange, different.”

This category includes two subcategories:

Sub-category 1.1: Weird Atmosphere (40/301; Acute: 35/198; Chronic: 5/103).

Typical sentences: “World look angelic, heavenly surroundings”, “Everything unreal”.

Sub-category 1.2: Strangeness about people’s expressive properties (43/301; Acute: 37/198; Chronic: 6/103).

Typical sentences: “Faces look sunken, as if they’re different people”, “Other people toys”.

Category 2: Experiences of Centrality/Invasion of Peripersonal Space (76/301; Acute: 65/198; Chronic: 11/103)

Patients feel uncomfortably center-stage. Others spy on them, send them messages, or hide something for them. Things are directed to them with personal meaning (see table 3).

Typical sentences: “Cat jumping into cardboard box signified a spiritual change in her,” “TV, radio, people on buses refer to him.”

Category 3: Alteration of Quality of Things (36/301; Acute: 31/198; Chronic: 5/103)

Patients’ experience of dimensions, colors, and shape of things is altered. This category includes macropsia, micropsia, dysmegalopsia, objects fragmented, flat, unrelated, or with colors shining (see table 4).

Table 4.

Categories 3, 4, and 5

Category	Core phenomenon	Typical sentences	Subcategory
3. Experiences of alteration of the quality of the environment (N = 30)	Dimensions, distances, and perspective may be distorted. The background may come to the foreground. Space may become homogeneous, 2D, and flat. Patients may lose the sense of having a “center” or a point of view. These experiences are accompanied by confusion and disorientation.	“For a while it seemed big and open then too close to me.” “Person sitting 6 feet away seemed to be at infinite distance.” “I felt spaceless.”	3.1. Alteration of the environment extension (N = 20) Typical sentences are: “Walls moving.” “Distances larger. Short road seemed miles and miles as if it opened up and swallowed me.”
			3.2. Spatial disorientation (loss and bewilderment; N = 10) Typical sentences are: “I was here and in a different dimension at the same time. I felt that the mind was based on the universe.” “On tube I don't feel I’m going anywhere, it's always in the same place.”
4. Alteration of quality of things (N = 36)	Dimensions, colors, and shape of things in the environment are altered. This category includes macropsia, micropsia, and dysmegalopsia, objects fragmented, flat, unrelated, or with colors shining and vivid.	“Writing and other things got smaller and smaller.” “Colors of jeans more realistic.”	4.1. Alteration of colors (N = 24) Typical sentences are: “Colours muddies.” “Brown looks different.”
			4.2. Alteration of geometric proprieties (dimensions and shape; N = 12) Typical sentences are: “Tables geometrically displaced.” “Neck of nurses seemed long.”
5. Itemization and perceptive salience (N = 21)	The environment is fragmented into a mere collection of itemized details, a disarticulated collection of unrelated items, or decontextualized details. These elements stand out, losing all connection with the surrounding space, disjointed from the context background.	“Locks on door and fridge frightened me.” “When I enter in the room, I am flooded by too much details. Too many objects in a room, too many people and notices. More details in objects.”

Typical sentences: “Writing and other things got smaller and smaller,” “Colors of jeans more realistic.”

This category includes two subcategories:

Subcategory 3.1: Alteration of colors (24/301; Acute: 20/198; Chronic: 4/103).

Typical sentences: “Colours muddies,” “Brown looks different.”

Subcategory 3.2: Alteration of geometric proprieties (dimensions and shape) (12/301; Acute: 11/198; Chronic: 1/103)

Typical sentences: “Tables geometrically displaced,” “Neck of nurses seemed long.”

Category 4: Alteration of the Quality of the Environment (30/301; Acute: 26/198; Chronic: 4/103)

Patients’ experience environment’s dimensions, distances, and perspective as distorted. The background comes into the foreground. Space becomes 2D, an immense flatness that at the same time may elicit sensations of claustrophobia. Spatial perspectives may become misleading. Patients may lose the sense of having a “center” or a point of view. These experiences are accompanied by subjective states of disorientation (see table 4).

Typical sentences: “Person sitting 6 feet away seemed to be at infinite distance,” “I felt spaceless.”

This category includes two subcategories:

Sub-category 4.1: Alteration of the environment extension (20/301; Acute: 17/198; Chronic: 3/103).

Typical sentences: “Walls moving”, “Short road seemed miles and miles as if it opened up and swallowed me”.

Sub-category 4.2: Spatial disorientation (10/301; Acute: 9/198; Chronic: 1/103).

Typical sentences: “I was here and in a different dimension at the same time.”, “On tube I don’t feel I’m going anywhere, it’s always in the same place”.

Category 5: Itemization and Perceptive Salience (21/301; Acute: 21/198; Chronic: 0/103)

Patients experience their environment as fragmented. Spatial Gestalt is a mere collection of unrelated items and decontextualized details standing out, losing all connection with the context background (see Table 4).

Typical sentences: “Locks on door and fridge frightened me,” “Flooded by too much detail. Too many objects in a room. More details in objects”.

Discussion

A number of phenomenological studies have investigated the experience of schizophrenia, including alterations of lived space.^3–6 However, much of this literature—while insightful and theoretically robust—is limited by the anecdotal nature of the evidence, often relying on small sample sizes or single-case studies. While such approaches provide insight into particular cases, they risk generalizing these insights to all subjects with the same condition, failing to consider subtypes or internal complexities.^38,39 By drawing on larger patient samples, we can use phenomenology to identify distinct subtypes of disorders.⁴⁰

Our study provides empirical evidence in support of theoretical claims made by phenomenological psychopathologists. Binswanger and Conrad, for instance, argue that, in schizophrenia, attuned space (ie, space shaped by one’s mood) “loses its homogeneity, consistency, and taken for grandness, which can lead to delusional mood or to revelatory experiences.” ^3,4,10 Phenomenologists seem to be largely in agreement over the nature of ASE in schizophrenia. For the sake of simplicity, we here discuss our findings in relation to Conrad’s conceptualization of the core of schizophrenic disturbance,^4,41 shedding light on abnormal phenomena underlying the genesis of schizophrenic symptoms, including delusional perception, thought control, broadcasting, and catatonia. He focuses on changes in the experiential field, especially in space perception.

Conrad develops a stage model that includes the following principal features:

1. Trema (stage fright), during which the foreground/background distinction is lost; the background loses its neutrality and becomes uncanny. “It is precisely the darkness as background which makes us tremble.” ^4(p177)

2. Anastrophé (from Greek ana = back + strophé = to turn), during which the patient feels like the entire world’s passive middle point. “The entire matter revolves around me.” ^4(p185)

3. Apophany (from Greek = revelation), during which the patient is stricken by details, jutting forward and pointing to the patient himself, having a special relationship and personal meaning to him. “The immediate, obtrusive knowing of significant meanings occur as a revelation.” ^4(p178)

Our findings suggest at least two important results: first, a substantial difference in the prevalence of ASEs between acute and chronic schizophrenia patients; second, empirical evidence in support of previous phenomenological theories of ASE in acute schizophrenia. We address these two results in turn. In the final part, we draw hypotheses about the transitions from ASEs to full-blown psychotic symptoms.

ASEs in chronic vs acute schizophrenia

Only a minority of chronic schizophrenia patients show ASEs as compared to acute patients. Nearly all acute patients (182/198) reported ASEs, whereas less than one-third of chronic patients (29/103) did. This suggests that the acute/chronic distinction is not simply one of duration but may constitute substantial experiential differences. Our interpretation is that, whereas, in acute states, the metamorphosis of lived space has an obtrusive and frightening quality, capturing the patients’ attention and becoming the focus of his distress, in chronic states, habituation to these abnormal experiences may prevail reducing the distress caused by them and their captivating charm. Also, in chronic states, the perplexing and confusing character of ASEs may be overshadowed by the patient’s interpretation of these experiences. ASEs in acute states (especially in the beginning stages) bring about a puzzling world transformation but, at later stages, they may progressively become the core of a revelatory experience and part of a meaningful new world structure. ASEs in chronic schizophrenia undergo a process of normalization. Apophany, once it has taken place, makes unfamiliarity become familiar and abnormality become normality.

ASEs in Acute Schizophrenia

Our results corroborate the idea that, in acute schizophrenia, the natural perceptual structure is loosened; this entails that obtrusive decontextualized details, releasing abnormal/delusional meanings, strike the patient and capture him in a private idiosyncratic understanding of the world (Matussek, quoted in Conrad⁴).

Sensation of strangeness and unfamiliarity and alteration of the quality of the environment parallel Conrad’s trema as they include perplexing and frightful phenomena like experiences of weird atmosphere, alteration of the environment extension, and spatial disorientation. The entire phenomenal field dissolves into a nebula of unrelated uncanny sensations. The environment loses its flesh-and-blood materiality. An ambiguous and elusive atmosphere emerges. The entire scenario is experienced as a theatrical stage. Space becomes 2D, perspectives become distorted, and the background comes to the foreground. This destructuring of the experiential field is accompanied by a feeling of mistrust.

Strangeness and unfamiliarity validate EAWE item 1.7 (“Disturbances of perceptual distance,” “Experience of infinite space,” “Figure/ground reversal,” “Loss of topographical orientation”). Alteration of the quality of the environment empirically substantiates EAWE item 1.8 (“Distorted experiences of space”) and particularly subtypes 1–4 (“Diminished perspectival orientation”).

Centrality/invasion of peripersonal space substantiates Conrad’s anastrophé. Centrality is a more severe degree of space deformation as compared to the previous ones as the loosening of the perceptual context is growing more pervasive. Objects appear out of their common-sense context and revolve around the subject, indicating to him that they concern him. Objects (or objects’ details) become obtrusive, invading the patient’s peripersonal space (PPS)—the portion of environment immediately surrounding one’s body.⁴² They release obscure messages that center on the patient. The world takes up a specific relationship to him, although he may be unable to pinpoint in what sense it does so. This precedes the emerging of a precise meaning that takes place in the apophany stage.

Centrality is discussed in EAWE’s domain 6 (“Existential reorientation”) item 6.9 (“Feelings of centrality”), in the EASE (5.2), and in the autism rating scale dimension 2 (“Invasiveness”), specifically subdimension 2.1 “Immediate Feeling of Hostility or Oppression coming from the Others”. Centrality and invasiveness appear to be strictly related and we may argue that there is an increasing gradient of intrusion of patients’ PPS subtending them. PPS is considered the founding element of the so-called “spatial-self,” subtending self/other demarcation: it has been argued that people with schizophrenia display shallower limits of PPS reflecting an impaired constitution of the spatial self and, consequently, a weaker differentiation from others.⁴³ People with schizophrenia need wider interpersonal space when interacting with others.^44,45

Alteration of quality of things and itemization/salience capture the core of Conrad’s apophany, especially the transformation of the unitary structure of the world into a collection of itemized details. An object, or one of its properties, can be decontextualized. A doctor’s coat may be perceived according to an increased prevalence of one of its properties, eg, its color. The coat’s “whiteness” stands out of the other properties of the coat (eg, its material and form) and the context in which it is used (eg, a clinic or a lab). Once decontextualized, this property compels the patient to discover its “hidden” meaning (eg, barbering, handling sharp instruments, thus suggesting a “slaughtering house atmosphere”).

Alteration of quality of things corroborates EAWE item 1.6 (“Changes in quality, size or shape of visual perceptions”). Itemization is also described in the EAWE item 1.3 (“Visual Fragmentation”), which includes breakup of a scene or object and captivation of attention by isolated details (see also EASE 1.12.1).

Transitions From ASEs to Full-Blown Psychotic Symptoms.

The cross-sectional nature of our data does not allow inferences about the pathogenetic transitions leading from early space abnormalities to psychotic symptoms through intermediate phenomena in which ASEs become progressively more pronounced. It is tempting to hypothesize a continuum of anomalous experiences from milder forms of derealization during which reality turns into mere appearance (unfamiliarity, alteration of the quality of environment/things), culminating in more severe derealization experiences during which some uncanny meaningfulness starts to be revealed (centrality and salience). During these earlier stages the objectivity of the world gets lost. Finally, a new objectivity takes place in the form of delusions, which explain, for instance, that anonymous forces have created these appearances to fully reveal some new and deeper meanings to the experiencing subject. Longitudinal studies are needed to confirm this hypothesis.

Further Perspectives

It would be highly valuable to investigate the relations between ASE, abnormal time experiences (ATE),¹⁸ and abnormal bodily phenomena (ABP).²² The disruption of the coherence of the environmental space (eg, disintegration of the appearance of external objects and itemization of external world experience) may be related to the anomalous constitution of the bodily self (eg, disruption of the implicit sense of being a unified, bounded, and incarnated entity) and to abnormal constitution of time (disarticulation of the synthesis of past, present, and future)—the milestones of our self-world engagement.⁴⁶

The qualitative nature of our data does not allow for statistical correlations but, in our sample, there is a considerable overlap between ASE, ATE, and ABP in acute schizophrenia patients as 41 acute patients showed both ASE and ATE, 32 patients showed both ATE and ABP, and 93 both ASE and ABP. A candidate unifying phenomenon is itemization, which is present in all these features of schizophrenic experience.

Reliable and valid assessment instruments are needed to search for quantitative correlations between these different facets of anomalous experiences in schizophrenia patients and look for neurobiological correlates of ASE, ATE, and ABP. Inquiries into the spatiotemporal features of the brain’s spontaneous activity seem to be suitable,^47,48 namely “temporal dysbalance” and “temporal fragmentation” in the spontaneous activity during internally directed processing.⁴⁹

Conclusions

Our study confirms that ASE is a key feature of the puzzling metamorphosis of the schizophrenia lifeworld. Our results empirically corroborate previous theoretical or semiempirical conceptualization of this core feature of the schizophrenic condition and validate or improve definitions of several items included in recent phenomenological scales for the assessment of anomalous experiences in persons with schizophrenia.

Detailed knowledge of the anomalies of lived space can help elucidate the phenomenal background of schizophrenia, anomalous behavior, and apparent incoherent or bizarre thinking and grasp the basic perceptual anomalies from which more complex symptoms like delusions may arise. Last but not least, fine-grained descriptions of these anomalies can inform translational studies on the neural and biological bases of the schizophrenia phenotype.

Limitations

Limitations include the archival nature of the data (written clinical notes), which might have impacted the accuracy of first-person descriptions; the lack of cognitive testing, which would have been useful to establish if and how the experiential and the cognitive levels are related to each other; and the lack of data about the possible effects of antipsychotics in relation to the overall evolution of anomalous self-experiences and world experiences.