The varieties of anomalous self experiences in schizophrenia: Splitting of the mind at a crossroad

Abstract

“Iwassimplysectionedagain,detachedfrommyrealself,observingwhat was being done to me in a third-person perspective.”Clara Kean (2009)Splitting of the self and self disturbances were important to Bleuler'sconcept of schizophrenia ( Bleuler, 1911), and a distorted, even loss of asense of self appears to be a core feature of the disorder (Nasrallah,2012;LysakerandLysaker,2010 ).Furthermore,aberrantselfexperiencesare highly salient to those who are diagnosed with schizophrenia ( Saks,2008;Kean,2009,2011)fromtheprodromalstagethroughoutthecourseof illness (Sass and Parnas, 2003; Nelson et al., 2008 ), and may increasevulnerability in those at risk for the disorder (e.g., Nelson et al., 2012;Koren et al., 2013). Thus, elucidating self-disturbances in schizophreniahas significant practical implications for implementing treatment strate-gies, but self-disorder is not even included in the current DSM-5 criteria.So how should we bridge this gap between the diagnostic criteria forschizophrenia, as prescribed by the American Psychiatric Association ononehandandthephenomenological first-personaccountsofschizophre-nia experience that centers around self disturbances on the other?This special issue on the theme of “self and schizophrenia” aims toaddress this disparity by highlighting recent advances in theories andframeworks for understanding self processing, as well as introducinginnovative state-of-the-art empirical research that underscores the di-verse manifestations and underlying mechanisms of self disturbancesthat span pre-reflective, automatic and implicit processes (e.g., corol-lary discharge, proprioception, body ownership) to higher-order, con-trolled and explicit cognitive functions (e.g., self-reflection, actionmonitoring, mentalizing, insight). An obstacle to this effort has beenthesheervarietyofframeworksanddefinitionswithrespecttothecon-cept of the self (Strawson, 1999). Given a lack consensus and commonvocabulary, empirical studies of self disorders and self disturbances di-verge further into self-report measures, interviews and experimentaltasks, spanning phenomenological, behavioral and neurobiologicallevels of analyses. Nevertheless, despite the wide range of theoriesand methodologies, there is a broad agreement on the core features ofself pathologies in schizophrenia. Anomalous sense of self in schizo-phrenia seems to involve a disturbance in the ownership of one'sbody, thoughts and actions, accompanied by faulty self-monitoring. Inthis issue, we present a diverse set of approaches to integrate neurobi-ological, cognitive and phenomenological explanations of anomalousself-awareness, self-monitoring, self-reflection and insight in theschizophrenia spectrum.First, recent advances in theories and models that address theetiology of self disturbances in schizophrenia are presented in threearticles.Sass'‘ipseitydisordermodel’clarifiesandexpandsuponhisear-lier theory that places disturbances of the minimal self or ipseity at thecore of schizophrenia. Ipseity disturbance is thought to arise mainlyfrom two interdependent phenomena of hyper-reflexivity and dimin-ished self-affection, and catalyzed by a loss of ‘grip’ on the word (Sassand Parnas, 2003). Despite strong predictions generated by thismodel,thespecificity,extentandunderlyingmechanismsofipseitydis-turbancehavenotbeenextensivelyexamined.Toaddressthespecificityquestion, Sass compared four conditions with known self aberrationsand observed some overlapping similarities but also profound differ-ences. While alienation of thoughts and bodily experiences was com-monly experienced in mania, psychotic depression, depersonalizationand schizophrenia, only schizophrenia was associated with “severeerosion of minimal self-experience or real confusion of self and other”(Sass, in press). Just how and why this erosion of ipseity occurs is un-known but the potential neurocognitive origins of basic self distur-bances in schizophrenia are proposed by Nelson and his colleagueswho highlight two cognitive mechanisms that may underlie basic self-disturbance in schizophrenia: source monitoring deficits, which maycontribute particularly to disturbances of “ownership ”and mineness(i.e., self-affection), and aberrant salience, which may contribute tothe hyper-reflexivity and disturbed “grip” on the perceptual field(Nelson et al., in press a,b).Given the compounding problem of self-monitoring deficit coupledwith aberrant salience in schizophrenia, depersonalization, derealiza-tion, passivity delusions, especially thought insertion or withdrawal,as well as “made feelings ”and made actions , may be understood asa reasonable response to ananomalous experience. Gray(in press) dis-sects the process of passivity delusions formation into three distinctstages, which begins with an abnormal self experience that engendersadelusional‘proto-hypothesis’. The existence of this proto-hypothesisinthecontextofnormalexperiencesthenleadstoafullblowndelusionthat is maintained despite evidence to the contrary. But what aspect ofthe anomalous self experience triggers the formation of a proto-