خودتجربه غیر عادی در مسخ شخصیت و اسکیزوفرنی ها: مطالعه مقایسه ای
|کد مقاله||سال انتشار||تعداد صفحات مقاله انگلیسی||ترجمه فارسی|
|38340||2013||12 صفحه PDF||سفارش دهید|
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Publisher : Elsevier - Science Direct (الزویر - ساینس دایرکت)
Journal : Consciousness and Cognition, Volume 22, Issue 2, June 2013, Pages 430–441
Various forms of anomalous self-experience can be seen as central to schizophrenia and other psychiatric disorders. We examined similarities and differences between anomalous self-experiences common in schizophrenia-spectrum disorders, as listed in the EASE (Examination of Anomalous Self Experiences), and those described in published accounts of severe depersonalization. Our aims were to consider anomalous self-experience in schizophrenia in a comparative context, to refine and enlarge upon existing descriptions of experiential disturbances in depersonalization, and to explore hypotheses concerning a possible core process in schizophrenia (diminished self-affection, an aspect of “ipseity” or minimal self). Numerous affinities between depersonalization and schizophrenia-spectrum experience were found: these demonstrate that rather pure forms of diminished self-affection (depersonalization) can involve many experiences that resemble those of schizophrenia. Important discrepancies also emerged, suggesting that more automatic or deficiency-like factors—probably involving self/world or self/other confusion and erosion of first-person perspective—are more distinctive of schizophrenia-spectrum disorders.
It has long been recognized that schizophrenic disorders involve profound alterations of mental state, in particular, changes in the experience of subjectivity, that is, varieties of anomalous self-experience. Although abnormalities of self or self-experience are not mentioned in the schizophrenia criteria of DSM IV-TR and ICD-10, they feature prominently in classic accounts. Bleuler (1911) stated that the malady always involves an affliction (“Spaltung”) of the self, writing that the self is never intact (“Ganz intakt ist dennoch das Ich nirgends”) (p. 58). Joseph Berze (1914) proposed that the primary disorder of schizophrenia was a fundamental alteration or “primary insufficiency” of self-consciousness. Recently, altered self-experience has again become a key issue in schizophrenia, through a series of theoretical contributions and related empirical studies. Sass and Parnas (2003) hypothesized that the core disturbance in schizophrenia is a particular disturbance of consciousness—an alteration in the sense of “minimal self” or ipseity that is normally implicit in each act of awareness. The term ipseity comes from ipse, Latin for “self” or “itself,” and is synonymous with what is sometimes termed basic or minimal self; it refers to a crucial sense of existing as a vital and self-identical subject of experience, with an automatic “mineness” of experience ( Ricoeur, 1992 and Zahavi, 1999). Sass and Parnas, 2003 and Sass and Parnas, 2007 suggest that this ipseity disturbance has two main aspects, which may seem mutually contradictory but are in fact complementary: hyperreflexivity and diminished self-affection. “Hyperreflexivity” refers to a kind of exaggerated self-consciousness, a (fundamentally non-volitional) tendency for focal, objectifying or alienating attention to be directed toward processes and phenomena that are normally experienced as part of oneself. Although hyperreflexivity does include some fairly volitional, quasi-volitional, or intellectual processes (these might be termed “hyper-reflectivity”), the hyperreflexivity in question is not, at its core, an intellectual or volitional kind of self-consciousness. Most basic in schizophrenia (according to Sass and Parnas) is an “operative” hyperreflexivity: the disrupting of awareness and action by means of an automatic popping-up or popping-out of phenomena and processes that would normally remain in the tacit background of awareness (where they normally serve as a medium of implicit self-affection), but that now come to be experienced in an objectified and alienated manner (see Merleau-Ponty, 1962, p. xviii re: “operative intentionality”—fungierende Intentionalität). Experientially speaking, hyperreflexivity can be manifest as an emergence or intensification of experience as such or a prominence of proximal over distal aspects of stimuli (see, e.g., Sass, 1994, re “phantom concreteness”), or else as focal awareness of kinesthetic bodily sensations, “inner speech,” or the processes or presuppositions of thinking. “Diminished self-affection” refers to a reduction in the very sense of existing as an aware subject or agent of action, i.e., to a diminished sense of existing as a first-person perspective on the world, an experiencing entity. One patient with schizophrenia described the condition of lacking this crucial but ineffable self-affection that is essential to normal ipseity: “I was simply there, only in that place, but without being present” (Blankenburg, 1991, p. 77). Hyperreflexivity and diminished self-affection are best conceptualized not as separate processes but as mutually implicative aspects or facets of the intentional activity of awareness: whereas the notion of “hyperreflexivity” emphasizes the way in which something normally tacit becomes focal and explicit, “diminished self-affection” emphasizes a complementary aspect of this very same process—the fact that what once was “tacit is no longer being inhabited as a medium of taken-for-granted selfhood” ( Sass, 2003, p. 170). This double-faceted disturbance of ipseity disrupts the normal, pre-reflective sense of “presence,” that is, of being an experiencing subject or self oriented toward objects or a world distinct from itself. In Husserlian phenomenology, this self-sense is variously referred to as the “I-center” or “central point of psychic life” or, more colorfully, the vital “source-point of the rays of attention” ( Bernet, Kern, & Marbach, 1993). Related work ( Sass, 2003 and Sass and Parnas, 2007) explores how such a disturbance might play a central explanatory role as the core feature (trouble genérateur) of schizophrenia. In this model, primary ipseity disturbance underlies the psychopathology, by giving rise to further psychic disturbances that themselves become features of the condition (see Section 4). Ipseity disturbance has been operationalized in a semi-structured interview, the Examination of Anomalous Self Experience (EASE) (Parnas et al., 2005) which examines experiences highly characteristic of schizophrenia spectrum disorders. Studies using the EASE or proxies thereof have demonstrated that such self-disturbances demarcate schizophrenia from psychotic bipolar illness (Parnas, Handest, Saebye, & Jansson, 2003) and from specific groups of non-schizophrenia-spectrum psychiatric patients (including affective syndromes, non-schizophrenic psychotic syndromes, and non-schizotypal personality disorders) (Haug et al., 2012, Parnas, Handest, et al., 2005, Raballo and Parnas, 2011 and Raballo et al., 2011), and aggregate selectively in the schizophrenia spectrum disorders identified in an at-risk population (Raballo and Parnas, 2011 and Raballo et al., 2011), with high interrater reliability (Møller, Haug, Raballo, Parnas, & Melle, 2011). There is evidence that the presence of such anomalies premorbidly or early in the prodrome predicts later development of schizophrenic psychosis (Nelson et al., 2012b and Parnas et al., 2011). Several hypotheses concerning neurocognitive correlates of these ipseity-disturbances have been put forward (Hemsley, 1998, Hemsley, 2005, Legrand and Ruby, 2009, Nelson, Fornito, et al., 2009, Sass, 1992 and Taylor, 2011). Taking this work further requires detailed study of the psychological and phenomenological structure of these anomalous self-experiences. One strategy for addressing this is through comparisons with other conditions involving disturbances of self-experience which, though not identical to those in schizophrenia, may be similar in important respects. Anomalies of self experience occur in other conditions, and at least some items of the EASE do appear in disorders outside the schizophrenia spectrum (Nelson et al., 2012b; Parnas, Handest, et al., 2005). Close comparison between conditions has the potential to reveal which characteristics are shared with other disorders and which are unique to schizophrenia, and may also help to illuminate how a fundamental alteration of self-experience might generate symptoms or structures of experience common in the schizophrenia spectrum. Significant overlaps with other disorders may help to clarify processes involved in schizophrenia, while disparities are also important, for they may suggest where (and perhaps why) processes differ, and what may be specific to the schizophrenia spectrum. The purpose of the present study was to determine the extent to which depersonalization disorder (DPD)—a non-psychotic condition distinct from schizophrenia yet characterized by a somewhat analogous (we do not say identical) form of ipseity disturbance—does and does not involve particular anomalies of conscious experience that are also highly characteristic of schizophrenia. The ipseity-disturbance hypothesis views schizophrenic self disorder as having several aspects (Sass and Parnas, 2003 and Sass and Parnas, 2007): basic (or “operative”) forms of ipseity disturbance, possibly rooted in neurobiological abnormalities unique to schizophrenia, as well as consequential and compensatory (defensive) forms of self-consciousness and self-affection. Although these latter develop secondarily, they become entrenched, quasi-automatized, and interwoven with the foundational anomalies. Given this model, it is reasonable to suppose that some schizophrenic anomalies of self experience have significant affinities with those in other conditions involving significant ipseity alteration, such as DPD. Identifying these sub-psychotic (or perhaps pre-psychotic) anomalies might aid in predicting the likelihood of a psychotic break in vulnerable individuals. There is already some evidence supporting the use of the EASE for this purpose (Nelson et al., 2012a and Parnas et al., 2011) and further studies exploring it are currently underway (Koren et al., 2012). The present study helps identify those EASE items most specifically linked with the schizophrenia spectrum. In this study we used items from the EASE to assess anomalies of self-experience in a common form of non-psychotic experience: depersonalization. Depersonalization, typically experienced as a spontaneous, non-volitional process, may arise as a psychological defense mechanism against anxiety, in which the sense of vital presence as a subject of experience is unpleasantly compromised, or even lost altogether (Medford et al., 2005 and Noyes and Kletti, 1977). DSM IV-TR describes depersonalization as “a feeling of detachment or estrangement from one’s self” (Diagnostic and statistical manual of mental disorders, fourth edition, text revision, 2000), often associated with reduced emotional responsivity and a feeling of loss of agency. Depersonalization was selected because it represents the clearest non-schizophrenic (and non-psychotic) manifestation of diminished self-affection (see above). Experiential alterations in depersonalization clearly involve an attenuation of self-presence, that is, of the very sensation of existing as an ego or subject of experience. Depersonalization is found in a variety of psychological disorders, and may be the third most common psychiatric symptom after anxiety and low mood ( Simeon, Knutelska, Nelson, & Guralnik, 2003). It can also exist independently of other symptoms or disorders (including the schizophrenia spectrum) in depersonalization disorder (DPD), a non-psychotic condition. The EASE is probably the richest and most rigorous available compendium of subjective anomalies in psychopathology. Its operationalized descriptions target alterations in the general form or structure of experience; they cover many types of anomalous subjective experience, allowing us to compare such experiences in schizophrenia and depersonalization in great detail. It should be stressed, however, that our use of the EASE in this study is distinctly non-standard. The EASE was designed for use in detailed psychiatric interviews involving extended probing of the patient’s experience. Here, however, we have applied it to published descriptions (usually autobiographical) of experiences. Potential problems with such usage are discussed below. Here it is worth mentioning two plausible sources of skepticism about the possibility of clinically relevant affinities between schizophrenia-spectrum and merely depersonalized experiences. Firstly, it is sometimes claimed that schizophrenic experiences, particularly delusions, involve a kind of “literalism” that is absent from non-schizophrenic or non-psychotic persons, whose descriptions are said to be merely “metaphoric.” It is important to remember, however, that the EASE is intended to capture sub-psychotic phenomena, i.e. experiences other than delusions and hallucinations – for example experiences of bodily or thought alienation, experiences that are directly lived, rather than delusional elaborations based on such experiences. Likewise, many experiences reported in the depersonalization literature (e.g., “Thoughts come almost like physical sensations—they pass up and down in my head”) describe directly lived psychosensory experiences and fulfill the explicit criteria for a range of EASE items. A second objection might be that schizophrenic experiences are somehow crucially more extreme or “bizarre” than those in depersonalization. However the depersonalization affinities we found not only fulfill explicit EASE criteria, they are, furthermore, difficult to distinguish in either quality or degree from the schizophrenic examples offered in the EASE (see below, and Table 1). Our hypothesis was that many, but not all, of the self-anomalies associated with schizophrenia (as listed in the EASE) would also be found in depersonalization. We are aware, of course, that similar-sounding descriptions could be masking significant differences on the phenomenological plane; subtle nuances of experience may evade easy capture in words. And when experiences truly are akin, they might still represent a final common pathway having different causes or sources. We also recognize that there may well be an underlying Gestalt-like essence in schizophrenia, not found in depersonalization disorder, that may give the experiences in question a somewhat different flavor (see Sections 2 and 4.4 below). Obviously, however, this does not mean that the Gestalt in question may not also resemble, in some important respects, certain other conditions. The EASE offers a nuanced way of investigating both similarities and differences that can potentially clarify both the conditions at issue and their possible pathogenetic pathways. We did not expect the two conditions to manifest identical disturbances of self-experience. However, certain similarities between the two conditions can help elucidate the way a key phenomenon might contribute to some aspects of schizophrenia. Discrepancies (i.e. EASE items not found in depersonalization) will help to identify what may be more particular or specific to the self-disturbance of schizophrenia, thereby indexing some fundamental feature of schizophrenia that cannot be mimicked by the more defensive processes central in depersonalization. Since the depersonalization subjects were not actually interviewed with the EASE, we cannot offer direct, quantitative comparisons of the frequency of particular anomalies in depersonalization versus schizophrenia spectrum conditions; our focus here is on whether certain anomalies seem also to occur in depersonalization. (An interview study using the EASE with depersonalization disorder patients would obviously be of considerable value.) This does not, however, undermine the main goals of this exploratory study, which are, first, to offer a preliminary phenomenological comparison of schizophrenia and depersonalization disorder and, second, to use the depersonalization analogue to support and refine hypotheses about the role of ipseity disturbance in schizophrenia.