Phenomenology of Anomalous Self-Experience

in Early Schizophrenia
Josef Parnas and Peter Handest
Disorders of self-experience were emphasized in clas-
sic literature and in phenomenological psychiatry as
essential clinical features of the schizophrenia spec-
trum disorders, but are neglected in the contempo-
rary psychopathology due to epistemologically moti-
vated distrust of studying anomalies of subjectivity.
Based on our own and other empirical studies, we
present here detailed clinical phenomenological de-
scriptions of nonpsychotic anomalies of self-experi-
ence that may be observable in the prodromal phases
of schizophrenia and in the schizotypal disorders.
Anomalies of self-experience are grouped according
the experiential domain that appears to be affected
and are illustrated by short vignettes or verbatim
quotes from the patients. It is suggested that disor-
ders of the self deserve further systematic empirical
investigations, also from an etiological perspective.
Self-disorders may turn out to be potentially useful as
a psychopathological organizer of the schizophrenia
spectrum disorders. Psychopathological emphasis on
these disorders may also help to integrate the search
for the neurodevelopmental mechanisms in schizo-
phrenia with developmental-psychological research
on the ontogenesis of the self.
Copyright 2003, Elsevier Science (USA). All rights re-
served.
The greatest hazard of all, losing ones self, can occur very
quietly in the world, as it was nothing at all. No other loss
can occur so quietly; any other lossan arm, a leg, ve
dollars, a wife etc.is sure to be noticed.
Sren Kirkegaard
P
SYCHOPATHOLOGY of subjective experi-
ence is today systematically neglected, partly
because of reliability concerns and partly due to
the prevailing behavioristic epistemological para-
digm.
1
This neglect is particularly perceptible in
the domain of schizophrenia. An instructive exam-
ple here is a construal of the so-called negative
symptoms of schizophrenia as purely behavioral
decits.
2
Yet, this construal does not exhaust these
symptoms diagnostic signicance as the funda-
mental trait features of schizophrenia,
3
nor does it
cohere with the patients perspective, often popu-
lated by quite positive anomalies of subjective
experience that cannot be faithfully described in
pure decit terms.
4
This serious and embarrassing
psychopathological lacuna is becoming glaringly
apparent thanks to the recent emphasis on early
diagnostic detection and therapeutic intervention in
schizophrenia.
5
These attempts have demonstrated
that operational psychiatry is short of descriptions
of subtle anomalies of subjective experience that
might be clinically useful for identifying individ-
uals at risk of imminent psychosis. Behaviorally
dened prodromal features of schizophrenia are for
that purpose prohibitively common in the general
population
6
and behavioral deviations alone,
without exploring subjective experience, lack the
specicity necessary to predict future schizophre-
nia
7
(p. 962). For that reason, nearly all early
therapeutic programs target already psychotic
cases, albeit in their early stages.
8
The aim of this paper is to present in clinical
detail (assisted by vignettes or verbatim state-
ments) phenomenological manifestations of anom-
alous self-experience that are detectable in the pro-
dromal phases of schizophrenia and in the
schizotypal conditions, a presentation that does not
exhaust the scope of anomalous experience in the
schizophrenia spectrum disorders (e.g., perceptual
aberrations will not be addressed here). Apart from
its potential theoretical signicance, this task is of
obvious pragmatic importance
9
: familiarity with
subtle, nonpsychotic anomalies of subjective expe-
rience is obviously crucial for early differential
diagnosis.
Morbid self-experience is dened here as a per-
vasive or frequently recurrent experience in which
ones rst-person experiential perspective or ones
status as a subject of experience or action is some-
how distorted. Anomalous experience described
From the Cognitive Research Unit, Department of Psychia-
try, Hvidore Hospital, University of Copenhagen, Copenhagen,
Denmark; and the Danish National Research Foundations Cen-
tre for Subjectivity Research, Copenhagen, Denmark.
Supported by a grant from the University of Copenhagen
(P.H.) and a grant from the Research Council of the Copenha-
gen Hospital Corporation (J.P.).
Address reprint requests to Josef Parnas, M.D., Dr. Med. Sci.,
Cognitive Research Unit, University Department of Psychiatry,
Hvidovre Hospital, Brndbystervej 160, 2605 Brndby,
Denmark.
Copyright 2003, Elsevier Science (USA). All rights reserved.
0010-440X/03/4402-0004$30.00/0
doi:10.1053/comp.2003.50017
Comprehensive Psychiatry, Vol. 44, No. 2 (March/April), 2003: pp 121-134 121
here is of not-yet psychotic intensity, i.e., we are
not dealing with delusional elaborations, halluci-
natory phenomena, or experiences of passivity al-
ready thematized by explanatory efforts. The pa-
tient is able to keep a distance to his altered
experience, a distance frequently expressed
through the conditional as if statements, e.g., it
feels as if my body does not belong to me.
SELF AND PSYCHOPATHOLOGY
Addressing the issue of experiential self-disor-
ders quickly confronts rather principal obstacles
and ambiguities. The term depersonalization,
coined in 1899,
11
is retained in the contemporary
psychiatric vocabulary, but with quite confused
usage
12,13
(p. 296). Despite a lack of convincing
empirical justication, the DSM-IV
14
and the ICD-
10
15
contain depersonalization as a separate disor-
der.
The notion of a self is deleted from the termi-
nology of DSM-IV and ICD-10. It is rarely used in
psychiatric literature, and usually in a colloquial or
psychoanalytic sense. Cognitive science, cognitive
psychology, and most of the analytic philosophy of
mind try to undermine the reality of the self
through various theoretical moves: (1) the self is
seen as a construct, a view that is saturated by
specic metaphysical (representational-computa-
tional) views on the nature of mind
1
; (2) the self is
a folk-psychological illusion
16
or (3) a narrative
ction
17
; or (4) the self is an illusion generated by
a linguistically improper use of the reexive pro-
noun.
18
None of these options is useful to a psy-
chiatrist, engaged in describing mental states of his
patients.
In accordance with our descriptive phenomeno-
logical orientation, a realist approach is adopted
here: the self is not merely a construct or a ction,
but possesses a mental reality of its own.
19-22
Phenomenologically speaking, one can address
the self on three hierarchically organized or
founded, but intertwined, levels. On the most ba-
sic, foundational level, the notion of self equals the
rst personal givenness of experience.
21
It is an
implicit, pre-reective egocentricity determining
the very manifestation of experience. Thus, an
experience is never a free-oating event, to which
a sense of being its subject is somehow subse-
quently added, i.e., experience and self are not
separate entities. Rather, the rst personal perspec-
tive is a way in which the experience articulates
itself.
23,24
This form of self-awareness will be ad-
dressed in more detail below. At a more explicit or
articulated, reective level, self-awareness is a
consciousness of an I as the invariant subject
pole of the manifold of experience and action. On
the most sophisticated or complex level, one may
speak of a person or social self, a self-referential
structure that comprises distinctive, individuated
characteristics, style, habits, and historical narra-
tive. Psychological concepts such as self-esteem
or self-image only make sense on this level of
selfhood.
SELF AND SCHIZOPHRENIA: EARLY
DESCRIPTIONS
Self-disorders in schizophrenia have always
been recognized as essential components of its
clinical picture. An absent reference to a self is
frequently merely terminological, because the
relevant phenomena are addressed in other terms
or in another theoretical framework.
Self-disorders were already described in detail at
the turn of the 19th/20th century. Especially French
psychiatrists published numerous case histories of
patients, characterized by profoundly altered self-
experience and who today would be diagnosed as
suffering from schizophrenia spectrum disor-
ders.
25-27
Eugene Bleuler
28
considered basic dis-
order of personality as a so-called complex fun-
damental feature of schizophrenia, stating that the
illness invariably involves an afiction of the self
(Ich-Spaltung): Ganz intakt ist dennoch das Ich
nirgends
28
(p. 58). The schizophrenic autism, an-
other of Bleulers fundamental symptoms, may
also be considered to encompass self-disor-
ders.
29,30
Kraepelin
31,32
claimed that a disunity of
consciousness (orchestra without a conductor)
was the core feature of schizophrenia.
An Austrian contemporary of Bleuler and Kra-
epelin, Joseph Berze
33
proposed that subtle alter-
ation of self-consciousness was the primary disor-
der in schizophrenia, specically detectable in the
The as if experiential mode in schizophrenia is thoroughly
described by Klosterkotter.
10
The expression basic disorder of personality, also used in
the ICD-8 & 9, refers to universal, impersonal aspects of a
person, i.e., the fundamental structure of the self, and not to
individuated personality features.
122 PARNAS AND HANDEST
incipient cases. He described this alteration as a
peculiar change, a diminished luminosity and af-
fectability of self-awareness and offered rich clin-
ical material to illustrate these phenomena. Jas-
pers
34
provided a commonsensical list of the
experiential modes in which a self is aware of
itself: (a) activity, comprising awareness of ones
existence and action, (b) unity, (c) identity over
time, and (d) me/not me demarcation. The sense of
self, says Jaspers, may be affected in any of these
modes. The vignettes on self-disorders presented
by Jaspers are often suggestive of the schizophre-
nia spectrum conditions, yet he offered no account
of theoretical or clinical signicance of self-disor-
ders. Kurt Schneider
35
alluded to a loss of ego-
boundaries in his description of passivity phe-
nomena. Scharfetter
36
modied Jaspers taxonomy
to comprise, in an order of allegedly increasing
complexity: vitality, activity, continuity, demarca-
tion, and identity. He considered many delusional
phenomena as compensatory reactions to self-dis-
orders. Most of his examples of altered self-expe-
rience in schizophrenia are, however, of a clearly
psychotic intensity.
Detailed descriptions of self-disturbances, fre-
quently associated with the explorations of the
sense and the nature of the self, are to be found in
phenomenological psychiatry.
37-44
The main mes-
sage from this line of work is that self-alteration
represents the primary disorder of schizophrenia,
conferring on it a unique Gestalt and reecting its
pathogenetic nucleus:
La folie (. . .) ne consiste pas ni dans un trouble du juge-
ment, ni de la perception, ni de la volonte, mais dans une
perturbation de la structure intime du moi
38
(p. 114).
RECENT STUDIES
There is no research that offers prospective pre-
morbid information on altered self-experience in
schizophrenia: none of the completed high-risk or
birth cohort studies collected data relevant to the
alterations of self-experience. One follow-back
study using objective information did, however,
reveal uidity of self-demarcation, lack of a coher-
ent narrative-historical self-identity, and other self-
disturbances to be prominent features of the pre-
schizophrenic states at school age.
45
An important and unique contribution in the
eld is the work of Gerd Huber and Joachim
Klosterkotter and their colleagues in Germany: in a
series of retrospective and, more recently, prospec-
tive clinical studies, they identied subtle (nonpsy-
chotic) affective, cognitive, perceptual, motor, and
bodily disturbances, designated as basic symp-
toms, many of which are specic to schizophrenia
and may precede its onset.
10,46-49
Several of these
disturbances reect anomalies in self-experience
(e.g., varieties of depersonalization, disturbances
of consciousness and action, distorted bodily ex-
periences). The basic symptoms are thoroughly
described in the Bonn Scale for the Assessment of
Basic Symptoms (BSABS),
50
translated into sev-
eral languages, including Danish, and available in
a preliminary English translation from the German
research group.
49
In a Norwegian study with naturalistic in-depth
interviews with 20 rst-onset schizophrenic pa-
tients,
51
three domains of pre-onset subjective
change were revealed: all patients had alarming
anomalies of self-experience; nearly all patients
complained of ineffability of their experiences; and
a great majority reported preoccupations with
metaphysical, supernatural, or philosophical is-
sues.
Our pilot study of 19 rst-onset patients with
schizophrenia
52
demonstrated very similar prodro-
mal proles. In another project, lifetime prevalence
of the BSABS-dened anomalies of subjective ex-
perience was compared between patients with re-
sidual schizophrenia and psychotic bipolar illness
in remission (DSM-IV): of all experiential anom-
alies, the disorders of self-experience were the
most signicant discriminators between the
groups.
53
More recently, we have completed de-
tailed, in-depth psychiatric interviews performed
by one of us (P.H.), including the BSABS, on 155
rst-admission cases and diagnosed according to
the ICD-10 research criteria: 57 suffered from
schizophrenia spectrum psychosis, 43 from schizo-
typal disorder, and the remaining 55 patients from
other, nonschizophrenia spectrum disorders (The
Copenhagen Prodromal Study).
54
Self-disorders
were analyzed using an ordinal a priori scale, of
high internal consistency, summing up the inter-
view items that pertained to most of the clinical
features described below. The data from our stud-
ies collectively indicate that self-disorders are spe-
cic to the schizophrenia spectrum conditions
(note that self-disorders are not a part of the
ICD-10 or DSM-IV diagnostic criteria of schizo-
phrenia) and mark the prodromes of schizophrenia.
ANOMALIES OF SELF-EXPERIENCE IN EARLY SCHIZOPHRENIA 123
Self-disorders correlate both with the negative and
the positive symptom scales of the Positive and
Negative Syndrome Scale (PANSS).
55
CLINICAL DESCRIPTIONS OF SELF-
EXPERIENCE IN EARLY SCHIZOPHRENIA AND
SCHIZOTYPAL DISORDERS
The vast majority of the rst admitted schizo-
phrenia spectrum patients in our series had been,
prior to their rst psychiatric hospitalization, in
contact with practicing psychologists or psychia-
trists. They were typically diagnosed as suffering
from a major affective disorder and were treated
with antidepressants. One reason for this initial
misdiagnosis is linked to the cryptic ways in which
the patients verbalize their complaints; it may also
be attributed to a widespread ignorance among
clinicians of the nonpsychotic subjective experi-
ence in schizophrenia.
The patients usually present nonspecic com-
plaints such as depression, fatigue, or lack of con-
centration. Blankenburg
41
speaks in this particular
context of a nonspecic specicity: a trivial
(nonspecic) complaint of fatigue may turn out, on
a close evaluation, to be associated with a perva-
sive inability to grasp everyday signications of
the world (a condition highly suggestive of schizo-
phrenia, hence specicity). As quite explicitly
pointed out by Berze,
33
self-disorders usually re-
veal themselves only after an attempt to penetrate
behind such surface complaints by an interviewing
clinician who is aware of potential manifestations
of self-disorders.
The difculty, which the patients confront in
reporting their experiences, is multi-determined.
The linguistic resources for expressing dimensions
of subjective experience, especially of the non-
propositional type, are not readily available. This is
especially true of anomalous self-experience, be-
cause it affects the very condition of experience
and its reportability. Adding to these difculties is
the fragility of the forms of consciousness in ques-
tion, with their unstable wavering of implicitpre-
reective into explicit-reective modalities.
The varieties of anomalous self-experience de-
scribed in the following sections are intimately
interrelated, yet classied according the phenome-
nological domain that appears to be affected. The
vignettes or quotes are from the patients investi-
gated in our research studies, unless it is indicated
otherwise. Sociodemographic characteristics of the
patients are sometimes altered in order to preserve
their anonymity.
Presence and Its Alterations
The phenomenological concept of presence sig-
nies that in our everyday transactions with the
world, the sense of self and the sense of immersion
in the world are inseparable: Subject and object
are two abstract moments of a unique structure
which is presence
56
(p. 430; our italics). We are
normally self-aware through our absorption in the
world of objects. We reside actively among the
things and in this absorption our self-awareness
operates at a pre-reective or tacit level. From a
phenomenological perspective, we can distinguish
here two aspects: a pre-reective self-awareness
(ipseity; Latin: ipse self, itself) and a correlative
pre-reective embededness in the world. These
experiential moments (i.e., non-independent parts)
deserve a more detailed exposition, because distur-
bances of presence appear to be the earliest and
most fundamental type of the prodromal experi-
ence in schizophrenia.
51,52
We may speak of a pre-reective self-awareness
whenever we are directly, non-inferentially, or
non-reectively conscious of our own occurrent
thoughts, perceptions, feelings, or pains; these ap-
pear always in a rst-personal mode of presenta-
tion that immediately reveals them as our own, i.e.,
it entails a built-in self-reference. To put it differ-
ently, when the experience is given in a rst-
personal mode of presentation to me, it is, at least
tacitly, given as my experience and counts as a case
of primitive or basic self-awareness, i.e., ipseity.
21
First-personal givenness is not a mere varnish that
the experience could lack without ceasing to be an
experience; it is precisely its rst-personal given-
ness that makes the experience subjective. Conse-
quently, to be aware of oneself is not to apprehend
a pure self apart from experience, but to be ac-
quainted with an experience in its rst-personal
mode of presentation, that is, from within. The
subject of experience is a feature or function of its
presentation.
21,22
Unreected immersion in the world is consid-
ered by phenomenology as a mode of intentional-
ity, i.e., a mode of consciousness object-directed-
ness. Phenomenology distinguishes between a
thematic, explicit, or objectifying intentionality
(e.g., when I am aware of this chair to the left from
me), and a nonreective, tacit sensibility, consti-
124 PARNAS AND HANDEST
tuting our primary presence to the world. This
so-called operative intentionality
56,57
is pre-re-
ectively functional without being engaged in any
explicit epistemic acquisition. It procures a back-
ground texture or organization to the eld of ex-
perience. It is upon such texture that explicit in-
tentionality congures its perceptual (e.g., seeing
this particular chair) or judgmental disclosures. It
is in the pre-reective mode that habits or dispo-
sitions become acquired. Operative intentionality
may therefore be considered as a condition of the
nonreexive, automatic attunement to the world,
i.e., common sense.
30,58
The most prominent feature of altered presence
in the pre-onset stages of schizophrenia is dis-
turbed ipseity, a disturbance in which the sense of
the self no longer saturates the experience. For
instance, the sense of myness of experience may
become subtly affected: one patient reported that
his feeling of his experience as his own experience
only appeared a split-second delayed.
The patient complains of unstable fullness or
reality of his self-awareness. He feels that a pro-
found change is aficting him, yet he cannot pin-
point what exactly is changing because it is not a
something that can be easily expressed in proposi-
tional terms.
The phrasings of such complaints may range
from a quite trivial I dont feel myself or I am
not myself to I am losing contact with myself,
I am turning inhuman, or I am becoming a
monster.
51
The patient may sense a sort of inner
void or a lack of inner nucleus, which is nor-
mally constitutive of his eld of awareness and
crucial to its very subsistence. Some of these com-
plaints point to the alterations of self-conscious-
ness, as if the luminosity of consciousness was
somehow disturbed or diminished (the term lumi-
nosity refers to the very manifestation, welling-up
or phenomenality of self-awareness
23
). The patient
does not feel being fully awake or conscious: I
have no consciousness, My consciousness is not
as whole as it should be, I am simply uncon-
scious, I am half awake, I have no self-con-
sciousness, My I-feeling is diminished, My I is
disappearing for me, My feeling of conscious-
ness is fragmented, It is a continuous universal
blocking
33
(pp. 126-129). This alteration of self-
consciousness is frequently associated with dimin-
ished affectability or reactivity of the self.
Case 1. I have lost all form of desire. I have no
contact to myself. I feel like a zombie; I am unable
to feel pleasure; everything appears indifferent. I
am not a part of this world; I have a strange ghostly
feeling as if I was from another planet. I am almost
nonexistent.
Psychiatrists describe such patients as anhedo-
nic, yet a diminished capacity for feeling pleasure
is only an aspect of a more profound alteration of
self-awareness.
The intentional aspect of altered presence is
usually described as lack of immersion in the
world, a lack of presence or a sense of imposed
detachment from the world. It may also manifest
itself as a phenomenological distance within per-
ception and action. In a normal perceptual experi-
ence, the object perceived is given directly, in the
esh so to say, but now it appears somehow ltered
and deprived of fullness. Perception is not lived but
is more like a mechanical, receptive, sensory pro-
cess, unaccompanied by its affective feeling-tone.
Case 2. Robert, a 21-year-old unskilled
worker, complained that for more than a year, he
had been feeling painfully cut off from the world
and had a feeling of some sort of indescribable
inner change, prohibiting him from normal life. He
was troubled by a strange, pervasive and a very
distressing feeling of not being really present, or
fully alive, of not participating in the interactions
with his surroundings. This experience of disen-
gagement, isolation, or ineffable distance from the
world was accompanied by a tendency to monitor
his inner life. He summarized his afiction in one
exclamation: my rst personal life is lost and is
replaced by a third-person perspective (He was
not at all philosophically read). In order to exem-
plify his predicament more concretely, he said, for
instance, that listening to music on his stereo
would give him an impression that the musical
tune somehow lacked its natural fullness; as if
something was wrong with the sound itself, and
he tried to regulate the sound parameters on his
stereo equipment, to no avail and only to nally
realize that he was somehow internally watching
his own receptivity to music, his own mind receiv-
ing or registering of musical tunes. He so to speak
witnessed his own sensory processes rather than
living them. It applied to most of his experiences
that, instead of living them, he experienced his
own experiencing. He reected on self-evident
ANOMALIES OF SELF-EXPERIENCE IN EARLY SCHIZOPHRENIA 125
daily matters and had difculties in letting things
and matters pass by and linked it to a long-lasting
attitude of adopting multiple perspectives, a ten-
dency to regard any matter from all possible points
of view
58
(pp. 124-125).
Roberts incertitude reects a sort of polyva-
lence (rather than ambivalence), linked to global
fragmentation of meaning, a loss of natural evi-
dence or loss of common sense, which is the
hallmark of the schizophrenic autism and perplex-
ity.
30,59
Robert resembles Anne, a patient described
in detail by Blankenburg.
41
Annes main and mo-
notonous complaint was her inability to grasp the
worlds natural signicance and appeal. Nothing
was self-evident for Anne, who had a distressing
difculty in the automatic understanding of people
and situations: it is not the question of knowledge;
it is prior to knowledge (. . .); it is so small, so
trivial; every child has it!!
41
Case 3. Maria, 24, reported that since the age
of 16, she was insecure and avoided others. She
didnt understand the others rules of the game,
felt always being outside the company, did not
have a sense of situation and could not under-
stand the interactions between people, nothing
came spontaneously, out of itself. I cannot read
the others; they are always a mystery!!
Lack of natural evidence should not be seen as
a deciency in the stock of explicit, thematic
knowledge, but as being indicative of a decient
pre-reective and direct grasp of the worlds sig-
nications, a decient pre-reective attun-
ement.
30
Such fragmentation of meaning may also
be described as a lack of perspectival abridge-
ment,
60
a lack of dominant point of view or a
dominant frame of reference, which normally
blocks out potential rival perspectives, and which
only can be realized through a medium of intact
selfhood (case 2).
The disturbances of presence exert profound re-
verberations on the sense of personal identity: un-
stable ipseity and lack of common sense create a
vacuum at the very core of ones subjectivity. This
vacuum deprives the patient of reliable disposi-
tional attitudes that normally imbue cognition and
emotion with a sense of typicality and familiar
direction. These identity disturbances are different
in kind from the disturbances seen in the non-
schizophrenia spectrum personality disorders (e.g.,
borderline or narcissistic patients). In the latter
case, the identity disorder operates on the level of
social self (self-image), with the sense of ipseity
and pre-reective immersion remaining intact.
The disturbances of presence seem to constitute
a foundation of the more explicit and articulated
anomalies of selfhood to described in the following
sections. Phenomena such as sense of identity over
time or demarcation presuppose ipseity in order to
arise at all.
21
For example, if a memory of a past
event is to contribute to my sense of identity over
time (a claim widely held in cognitive science), it
can only do this job in so far as the past event is
being remembered as having taken place in my
eld of awareness, as something which was origi-
nally experienced from my rst-person perspec-
tive.
Sense of Corporeality and Its Alterations
Conscious experience is usually never purely
cognitive or spiritual but is closely intertwined
with our bodily existence and experience (embod-
iment, incarnation). Embodiment is a fundamental
condition of selfhood (see Depraz
61
for a recent
comprehensive account). It is a prerequisite of the
constitution of objective space, populated by mind-
independent objectsa view shared by phenome-
nology
56
and contemporary analytic philosophy of
mind.
62,63
The body has ambiguous experiential
status: at the one extreme it is a lived body
(Leib; chair), i.e., subjective, animated body,
identical with the self; at the other extreme it is
experienced as a physical, spatially extended ob-
ject or thing (Korper; corps).
57
Incessant os-
cillation or interplay of gradations
61
between these
experiential bodily modes constitute a tacit foun-
dation of all experiencing.
In the incipient schizophrenia a variety of dis-
sociations of the bodily experiential modes may be
observed, with a striking tendency to experience
ones body predominantly as an object: there is an
increasing experiential distance between subjectiv-
ity and corporeality (disembodiment). The fol-
lowing vignette dramatically illustrates such a s-
sure or disjunction:
Case 4. I am no longer myself (. . .) I feel
strange, I am no longer in my body, it is someone
else; I sense my body but it is far away, some other
place. Here are my legs, my hands, I can also feel
my head, but cannot nd it again. I hear my voice
when I speak, but the voice seems to originate from
some other place. He has difculty in localizing
126 PARNAS AND HANDEST
his own person: Am I here or there? Am I here or
behind? When he does something, he has a feel-
ing of observing his actions as a witness, without
being actively involved: One might think that my
person is no longer here (. . .) I walk like a ma-
chine; it seems to me that it is not me who is
walking, talking, or writing with this pencil. When
I am walking, I look at my legs which are moving
forward; I fear to fall by not moving them cor-
rectly. When he watches himself in a mirror, he is
afraid of staying there or is not sure on which side
of the mirror he actually is (. . .) His reason is
intact; he knows very well that he is himself
26
(p.
138, our translation).
A common early change is a sense of being
detached, disconnected from ones body, which
feels somehow alien or not tting the subject.
For example, the patient may say that he feels as
if his body was too small to be inhabited or as
somehow, indenably, uncomfortable to live with.
Amore clear distortion of experience consists of
a loss of bodily coherence: bodily parts are felt as
if disconnected from each other. This experience
may take an alarming intensity, where the psycho-
corporeal unity disintegrates, a sense of fragmen-
tation accompanied by a (pre)-psychotic panic of
literal dissolution (going into pieces).
Another, experientially articulated, disturbance
consists of a feeling of morphological change: the
body or its parts feel heavier/lighter/smaller/larger/
longer/shorter. One patient reported that he fre-
quently had a feeling that his body became very
small, yet at the same time was lling up the entire
room: I feel a simultaneous implosion and explo-
sion. Such feelings may be accompanied by op-
tical illusions of actual experience of bodily
change. The most famous of the latter is the mir-
ror phenomenon (signe du miroir,
64
Spiegel-
phanomen
50
), where the patient inspects his face
in a mirror because of feelings of self-alteration:
the eyes may look dead, empty, or the face seems
deformed. A subtler variety of this phenomenon
consists of avoiding ones mirror image (which is
perceived as threatening or provoking).
Certain identity disturbances, such as a peculiar
sentiment of being much younger or older than
ones chronological age are probably linked to the
distortions of bodily self-awareness: I have a
strange, almost physical feeling, as if I was a little
girl, reported a 23-year-old female patient.
Disturbances of subjectivity may be manifest in
motor performance. Motor or verbal acts may oc-
cur without or despite the patients will and inter-
fere with his actions or speech but are not yet
regarded as being imposed by some external
agency.
Case 5. A former paramedic reported that
many years prior to the onset of his illness he
occasionally experienced (e.g., when driving in an
ambulance and to a drivers surprise) that he would
involuntarily utter a few words, entirely uncon-
nected with his train of thoughts. He immediately
continued to speak in a relevant way or made some
cliche remarks in order to cover up for this embar-
rassing episode.
Motor block (blockage of intended actions) oc-
curs as a sudden and brief sense of paralysis where
the patient is unable to move or speak. Another,
and frequent phenomenon is desautomatization of
motor action in which habitual motor performance
(e.g., dressing, teeth brushing) requires conscious
attention and sense of effort:
Case 6. Afemale library assistant reported that
prior to the onset of her illness she was alarmed by
a frequently recurring experience that replacing the
returned books from a trailer on the library shelves
suddenly required attention: She had to think how
she was to lift her arm, grasp a book with her hand,
turn herself to the shelf, etc.
Stream of Consciousness and Its Alterations
The stream of consciousness (also designated as
stream of thoughts) is a sense of consciousness
as a temporal ux.
65-67
This ux oscillates between
introspectible static moments of explicit cogni-
tive-emotional activity and vaguely articulated ten-
dencies of transitions into new directions (fringes
of consciousness
65
). Even though the stream (es-
pecially of thoughts) may be quite saccadic, self-
awareness remains uninterrupted as the same ow.
In a given temporal moment of the stream, its
constituent contents (e.g., thoughts, images, sensa-
tions) are co-conscious, i.e., united in an experien-
tial whole.
68
The self permeates this whole as its
rst personal perspective: there is no distance be-
tween my thoughts and myself. Apart from certain
reective acts, my thinking is at a zero point of
orientation.
43,57
Consciousness is essentially non-
spatial in the physical sense of space, although
certain perceptual contents are experienced with
spatial dimensions. Consciousness is never experi-
ANOMALIES OF SELF-EXPERIENCE IN EARLY SCHIZOPHRENIA 127
enced as a thing with specic location or with
spatial characteristics; its introspective contents are
transparent or immediately given in a nonspatial
way (i.e., the contents are not like physical objects
lending themselves to a description in perspectival
spatial terms).
A fundamental change of the stream of con-
sciousness in the early phases of schizophrenia
consists of an increasing experiential ssure be-
tween the self and its contents (as it was the case
for the sense of embodiment). Mental contents
become quasi-autonomous, bereft of their natural
ipseity dimension. Thoughts may appear as if from
nowhere, are felt somehow ego-less, decentred or
at a distance from the self. They may interfere with
the ongoing stream of thoughts (thought interfer-
ence), and are often described by the patient
through specic private designations such as au-
tomatic, acute thoughts, thought-tics, etc. The
patient still self-ascribes his thoughts as his own,
their content is often quite neutral and there is no
sense of ongoing inner resistance or mental strug-
gle (as in the case of obsession).
The patients frequently report hyper-reexive
form of introspective experience. Hyper-reexivity
refers to forms of exaggerated self-consciousness
in which a subject takes itself as its own object,
60
a phenomenon that is closely associated with ipse-
ity disturbance and loss of meaning.
Case 7. If a thought passed quickly through his
brain (. . .), he was forced to direct back his atten-
tion and scrutinize his mind in order to know
exactly what he had been thinking. In one word he
is preoccupied by the continuity of his thinking. He
fears that he may stop thinking for a while, that
there might have been a time when my imagina-
tion had been arrested (. . .) He wakes up one
night and asks himself: Am I thinking? Since
there is nothing that can prove that I am thinking,
I cannot know whether I exist. In this manner he
annihilated the famous aphorism of Descartes. . .
26
(p. 179, our translation).
Intense hyper-reexivity tends to objectify the
introspective experience: the content of experience
is less lived and appears more like an inspected
object (see case 2). For example, the inner speech
becomes transformed from a medium of thinking
into an object-like entity with quasi-perceptual
characteristics (Gedankenlautwerden). Many pa-
tients exhibit a subtler spatialization of inner ex-
perience. They describe their thoughts or experi-
ences in physical terms, as if possessing object-like
spatial quality (dense and encapsulated thoughts)
or locate them spatially (my thoughts feel mainly
in the right side of the brain; it feels as if my
thoughts were slightly behind my skull). One
patient reported an experience as if she looked at
the world somehow much far from behind; her
point of perspective was felt as if displaced
some centimetres behind.
Case 8. A patient reported frequently occur-
ring surrealistic experiences, by which he meant
episodes where the next thought arrives before the
rst one is nished and a feeling that the
thoughts are layered one upon another. He felt
sometimes as if his thoughts originated in three
distinct strata of the brain.
Hyper-reexivity may sometimes possess a
compensatory role, making up for perplexity
41
(see
case 9) or it appears as a more primary afiction
(case 10). In all circumstances, the thinking pro-
cesses lose their sense of subjective mastery and
are experienced as increasingly alienated.
Case 9. A 34-year-old university graduate re-
ported that for many years trivial matters fre-
quently came to occupy his mind. For example,
while reading a novel written in the rst person,
and encountering a sentence like she said that he
must return tomorrow he immediately started to
reect on the reasons for using the personal pro-
nouns, to nally conclude that it has something to
do with communication. He then turned his atten-
tion to the word communication and continued
to think on the necessity to communicate, etc. He
could also reect upon the fact that the air distrib-
uted itself in the rooms of his apartment.
Case 10. I bypass a window display of a shop
in which there are exposed bicycles and bicycle
parts; [in a wheel] all the spokes cross each other in
sharp angles before they reach the axel, . . .the axel
turns around with the spokes. No, it is not the axel
that rotates; it is the bar, a piece of steel. The axel
does not exist; it is just a mathematical line, per-
pendicular to the plane of the wheel that is deter-
mined by the spokes, by 40 straight lines. But this
is not necessary either: only two lines are needed to
determine a at surface. And the circumference?
2r is the expression for the length of the felloe, or
more precisely, for the theoretical circumference,
outlined by this inexact circle (i.e., the felloe). Are
128 PARNAS AND HANDEST
we able to conceive an ideal line by paying atten-
tion to the lines in nature? Is Spencers claim that
mathematics originates from experience and induc-
tion correct? (. . .) These associations. . .would not
seem to me as sick if I were able to master them,
like someone who calmly reects on the matters
that he is working with, contemplating some pro-
fessional problems. But when I am thinking in this
way, without being able to stop it. . .I have no
mastery over the course of these ideas. . .it seems
to me as if it is not me who generates them. . .
26
(p.146, our translation and italics).
This state may intensify into a thought pressure
(Gedankenjagen), where the patient is over-
whelmed by a myriad of unconnected thoughts
going in different directions; loss of meaning or
lack of an organizing theme is the cardinal feature
of this symptom; moreover, the contents are fre-
quently affectively neutral (as opposed to, e.g.,
depressive ruminations). One patient reported a
feeling as if his consciousness consisted of mul-
tiple emanating sources, disconnected from each
other and each pulsating at its own pace. A
seemingly opposite experience is of a thought
block, where thoughts abruptly disappear or grad-
ually fade away. A variant of this phenomenon is a
sudden and total discontinuity of self-awareness:
the patient may report that for some seconds he
loses awareness of his activity, e.g., he does not
know how he got from his living room to the
kitchen or nds himself somewhere in the city
without knowing how he got there. Less character-
istic phenomena comprise difculties in initiating
and carrying through the thinking processes: the
patient complains of diminished ability to generate
thoughts or of general slowness of cognition and
inability to reach its desired goal (disturbances in
thought intentionality and goal-directedness).
Communication of meaning to others may be dis-
torted (disturbed self-expression). The patient ex-
periences a mismatch between his cognitive-emo-
tional state and its outward expression, perceiving
his own behavior, gestures, facial expressions, or
speech as somehow disgured and out of control, a
condition usually associated with hyper-reexivity.
Hyper-reexivity and diminished ipseity often lead
to a peculiar and pervasive splitting or a doubling
of the self (Ich-Spaltung) into an observing and
observed ego, none providing a reliable sense of
ipseity (case 2). This experience may intensify
prior to a frank psychotic episode: it may articulate
itself as an inner struggle or oscillation between the
good and the evil parts or between different
selves. Although the normal processes of reection
and imagination also involve experiential ego-split,
they nevertheless happen in a unied eld of ex-
perience, in which the sense of ipseity never ques-
tions itself.
Self-Demarcation and Its Alterations
Inability to discriminate self from not-self was
described as transitivism by Bleuler.
28
This phe-
nomenon attracted attention of numerous authors,
typically in connection with the Schneiderian
symptoms such as delusions of external inuence
and thought broadcasting. Weak ego boundaries
were also an important topic for psychoanalysis
and inherent in the concept of psychotic projec-
tion.
69
In the neurocognitive investigations of the
Schneiderian symptoms,
70,71
the sense of owner-
ship of experience and the sense of agency are
believed to be generated by inferential self-moni-
toring mental processes (but see a critique by Gal-
lagher
72
). From a phenomenological perspective
however, the me/not-me demarcation is a consti-
tutive moment of the experience itself; in other
words, the sense of myness of experience is just an
aspect of the nonreexive self-awareness (ipseity).
Inferential reection seems to arise only post hoc,
as a consequence of a decient sense of myness:
Case 11. A young schizotypal patient fre-
quently contemplated his own ego-boundary. He
thought about this uid transition between me and
the world: it must consist of a mixture of air
molecules, sweat droplets and tiny fragments of
skin debris.
In the prodromal phases of schizophrenia and in
the schizotypal conditions, one may observe subtle
transitivistic phenomena that are purely experien-
tial, i.e., unaccompanied by delusional elabora-
tions. The following case is paradigmatic of such
experiences:
Case 12. A young man was frequently con-
fused in a conversation, being unable to distinguish
between himself and his interlocutor. He tended to
lose the sense of whose thoughts originated in
whom, and felt as if his interlocutor somehow
invaded him, an experience that shattered his
identity and was intensely anxiety provoking.
When walking on the street, he scrupulously
avoided glancing at his mirror image in the win-
ANOMALIES OF SELF-EXPERIENCE IN EARLY SCHIZOPHRENIA 129
dowpanes of the shops, because he felt uncertain
on which side he actually was. He used to wear a
wide and tight belt in order to feel more whole
and demarcated. He was very much attracted by
the philosophy of Merleau-Ponty, whom he con-
sidered as the only philosopher who truly had
grasped the fundamental subject-object reversibil-
ity.
Solipsism and Existential Reorientation
Mller and Husby observed, conrming a com-
mon clinical experience, that young pre-schizo-
phrenic patients become excessively preoccupied
with philosophical, supernatural, and metaphysical
themes: Had to dene and analyze everything;
needed new concepts for the world and human
existence; absorbed by new ideas or interests, grad-
ually taking over my way of life and thinking.
51
This search for a transcendent meaning (i.e., meta-
physical quest) is of course not restricted to schizo-
phrenia but is a distinctive and pervasive charac-
teristic of all human thought. It is fuelled by a
paradox or a discordance intrinsic to the human
self-relation, what Dieter Henrich, a contemporary
German philosopher, designates as the basic rela-
tion
73
: on the one hand, we experience ourselves
as spiritual, unique, and autonomous free beings;
on the other hand, we are also self-aware as nite,
causally determined entities, belonging to the
world order of natural objects.
The origins of transcending thinking arise out of the fol-
lowing states of affairs (. . .): the unintelligible self-relation
due to which self-consciousness exists; the (. . .) opposi-
tion of reality and self-consciousness (. . .); and the unin-
telligibility of nite individuality in the world order. Taken
together, they constitute what can be experienced as the
darkness that inheres in the basic relation. That darkness
calls for a [metaphysical] thinking in which these states of
affairs can be comprehended (. . .) with a clarity that is not
available in the basic relation itself
73
(p. 126; our italics).
Anomalies of experience so far described, involv-
ing subjectivization of the world, disembodiment,
and instability of the self, shatter the experiential
equilibrium normally characteristic of the basic
relation and intensify the metaphysical quest,
thereby leading to the existential reorientations de-
scribed by Mller and Husby.
The patients altered ways of experiencing tran-
scend commonsensical, everyday metaphysics:
reality seems somehow mind-dependent, physi-
cal causality loses its regulatory ontological role,
other minds are either enigmatic entities or be-
come malevolent constructions, the subject-object
distinction is blurred and the normally tacit mental
processes are available for introspective gaze
9
(see
case 2). The term solipsism*, denoting here a
paradoxical blend of subjectivization of the world
and of others and of self-dissolution, seems to
capture such a position adequately.
60,74
It is a po-
sition motivated by a profoundly altered self-expe-
rience (cases 13 through 16) and cognitively elab-
orated into a nexus of interests and beliefs pointing
to a new existential orientation.
Case 13. A young patient reported that he had,
in brief moments, a feeling that only the objects in
his current eld of vision were real, as if the rest of
the world, including most familiar places and per-
sons, did not really exist. Probed about suicidal
intentions, he replied: No, I could never kill my-
self. I cant imagine the world not being repre-
sented [by me].
Feelings of centrality may be prominent in such
conditions.
Case 14. Aformer physician, when working in
the emergency room of a provincial hospital, ex-
perienced, during eeting moments, a feeling that
he was the only true doctor in the entire world and
the fate of humanity was in his hands. He quickly
suppressed such feelings as entirely nonsensical.
Case 15. When I hear a dog barking or a cat
screaming far away, I instantly get a feeling that
they bark and scream at me. When I listen to the
radio, I get this thought that one is trying to let me
understand something. I know that it is pure rub-
bish
50
(p. 78, our translation and italics).
Mimetic experiences may rarely occur, usually
as an aspect of feelings of centrality: the patient,
while in motion, experiences similar movements of
inanimate objects or of other people. He may feel,
in the as if mode, that he is somehow bound to
imitate others or that others imitate him.
Case 16. Luc, 17 years old, reports: I made
the same gestures as others, but ahead of them.
Then he corrects himself: following them, but
this does not seem satisfactory either. He hesitates
between these two versions, and ends up choosing
*The term solipsism (Latin: solus sole; ipse self) refers
in philosophy to a position claiming that only my consciousness
exists. I can never be sure if the world and other minds exist; at
best they are my minds own creations
130 PARNAS AND HANDEST
the one in which he precedes the others
75
(p. 107,
our translation and italics).
Solipsistic position often entails a sentiment of
having a unique access to the deeper and more
essential layers of reality, inaccessible to other
people. It may therefore become a source of a quite
distinctive type of grandiosity: the patient consid-
ers other people as pitiable, ontologically ignorant
morons, solely chasing supercial and material
aspects of existence.
Case 17. Thomas, 22 years old and a highly
gifted and successful student of mathematics, hos-
pitalized with a pre-psychotic panic, reported that
he felt to be quite different from other people since
his very early childhood. He never had intimate
friends, yet was very popular in the primary school
because of a gift for inventing imaginary games. At
the interview he mentioned that he always believed
in the existence of a world-soul. All humans
were, metaphorically speaking, like water drops
fallen on earth, and so irreversibly separated from
this soul. He, however, still felt in touch with the
world-soul, like a droplet yet hanging in a tiny
manner to its original source. Asked about magical
abilities, he responded that ability was a wrong
word to use; rather, he felt as if he somehow
contained the entire universe within his own con-
sciousness. He was perfectly aware of the impos-
sibility of its being true in the ordinary causal
sense. He felt superior to others and was always
amazed by a profound banality of ordinary human
strivings and interests.
TRANSITION TO PSYCHOSIS
In the transition to psychosis, anomalies of sub-
jective experience become thematized in the emer-
gent delusions, hallucinations, or passivity experi-
ences,
10,33,36,76
a process sometimes called as
psychotic re-personalization.
77
The following
reconstruction of the illness evolution illustrates a
transition from a prodromal phase into a frank
psychosis.
Case 18. Peters history of illness: January
1985: strange change is affecting him, feels
self-disgust, has lost contact to himself. Au-
gust 1985: increasingly preoccupied by existential
themes and Indian philosophy, perhaps meditation
could help. Increasingly isolated. January 1987:
feels fundamentally transformed, something in
me has become inhuman, no contact to his
body, feels empty, has to nd a new path in his
life. January 1988: is of the opinion that Indians
are superior compared to other human races; they
perhaps have a mission to save our planet. Septem-
ber 1992: preoccupied by recurring thoughts about
extraterrestrials. January 1993: convinced that In-
dians are reincarnated extraterrestrials. April 1994:
feels that he is being brought here each day from
another planet in order to assist Indians in their
salvatory mission. June 1994: rst admission to a
psychiatric ward, 24 years old
78
(details added
upon personal communication).
The initial ineffable self-transformation is being
progressively infused with content, reected by
new interests in the Buddhist thought and moti-
vated by charismatic and eschatological concerns.
In the operational terminology, self-disturbances
evolve through odd or overvalued ideas and cul-
minate in the emergence of bizarre delusions.
Many classic psychopathologists interested in the
diagnostic specicity of delusions
34,79-80
have ob-
served that there is a characteristic metaphysical
coloring of the content of delusions that is specic
to schizophrenia. This taint, in our view, is closely
linked to the solipsistic position described above.
Many such delusions would be considered as being
bizarre on the face of their implausible or impos-
sible content. Yet, what is being perceived as bi-
zarre in this kind of delusions is not only the
content as such, but also an altered way of the
patients experiencing, transparent through this
content.
81
The metaphysical taint indicates
something about the nature of the experienced self-
relation; that is to say, it points to a disturbance of
the self as a founding instance.
42
CONCLUSIONS AND IMPLICATIONS
We have tried to provide descriptions of the
anomalies of self-experience that are detectable in
the schizophrenia spectrum disorders; descriptions
that do not conform to the pre-formed operational
checklists, and that neither can be found in the
standard contemporary texts on schizophrenia. We
have alluded in the introduction to a systematic
neglect of subjective experience in psychiatry. Re-
cently, other voices have deplored a decline of
clinical nesse and skill in psychiatry.
3,82
Yet, a
necessity of studying subjective experience will
not go away just because it is difcult. A faithful
description of experience is the rst step in any
taxonomic project or in any effort to correlate
pathological experience to its biological substrate.
ANOMALIES OF SELF-EXPERIENCE IN EARLY SCHIZOPHRENIA 131
This prerequisite, articulated in psychopathology
by Karl Jaspers in 1923,
34
has been more recently
expressed by the philosopher Thomas Nagel
83
in
the context of consciousness research: a necessary
requirement for any coherent reductionism is that
the entity to be reduced is properly understood (p.
437). Exploring subjective experience requires ap-
propriate phenomenological methodology, inte-
grated in systematic empirical designs.
84,85
When
practicing this approach we have been struck by
two quite typical reactions from the interviewed
patients: one of relief, when the patient realizes
that his strange world of experience is not entirely
unique or private since it seems familiar to the
psychiatrist, and second, of amazement, that pre-
viously encountered mental health professionals
never had asked him questions about his inner life.
The incipient stage of schizophrenia is portrayed
here as a disorder of consciousness, although cer-
tainly of a different kind than pathologies observed
in organic delirious conditions. Profound alter-
ations of the self mark this stage and are also
observed in the schizotypal conditions, perhaps
indicative in the latter case of a future risk for a
psychotic progression. The described phenomena
appear to point to the core phenomenological as-
pects of schizophrenia and therefore deserve fur-
ther systematic empirical investigations, also from
a pathogenetic perspective. Potential demonstra-
tion of pathogenetic signicance of self-disorders
may signicantly alter our perspective on schizo-
phrenia: rst, it may help integrating the search for
neurodevelopmental factors in schizophrenia with
the developmental-psychological studies on the
ontogenesis of the self
86
(pp. 28-80). Second, the
schizophrenia spectrum disorders need not to be
conventionally dened as an aggregation of essen-
tially disconnected symptoms, but may rather con-
stitute a disorder essentially linked to anomalies of
self-experience.
Solipsism and the existential enactments of
anomalous self-experience impose certain limita-
tions upon the medical model view of schizophre-
nia. In the medical model, the symptoms of the
illness and the self of the patient can usually be
neatly separated. Yet, in schizophrenia we seem to
be confronted with a blend of the two, an aspect
that has important implications for diagnostic and
therapeutic practices.
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