Louis A. Sass

Self, Solipsism, and Schizophrenic Delusions

We propose that typical schizophrenic delusions develop on the background of preexisting anomalies of self-experience. We argue that disorders of the Self represent the experiential core clinical phenomena of schizophrenia, as was already suggested by the founders of the concept of schizophrenia and elaborated in the phenomenological psychiatric tradition. The article provides detailed descriptions of the pre-psychotic or schizotypal anomalies of self-experience, often illustrated through clinical vignettes. We argue that delusional transformation in the evolution of schizophrenic psychosis reflects a global reorganization of consciousness and existential reorientation, both of which radiate from a fundamental alteration of the Self. We critically address the contemporary cognitive approaches to delusion formation, often finding them inconsistent with the clinical features of schizophrenia or implausible from a phenomenological point of view.

Rediscovering Psychopathology: The Epistemology and Phenomenology of the Psychiatric Object

Questions concerning both the ontology and epistemology of the “psychiatric object” (symptoms and signs) should be at the forefront of current concerns of psychiatry as a clinical neuroscience. We argue that neglect of these issues is a crucial source of the stagnation of psychiatric research. In honor of the centenary of Karl Jaspers’ book, General Psychopathology, we offer a critique of the contemporary “operationalist” epistemology, a critique that is consistent with Jaspers’ views. Symptoms and signs cannot be properly understood or identified apart from an appreciation of the nature of consciousness or subjectivity, which in turn cannot be treated as a collection of thing-like, mutually independent objects, accessible to context-free, “atheoretical” definitions or unproblematic forms of measurement (as is often assumed in structured interviewing). Adequate and faithful distinctions in the phenomenal or experiential realm are therefore a fundamental prerequisite for classification, treatment, and research. This requires a multidisciplinary approach, incorporating (among other things) insights provided by psychology, phenomenological philosophy, and the philosophy of mind.

Self-disturbance and schizophrenia: Structure, specificity, pathogenesis (Current issues, New directions)

This paper offers an overview and clarification of the ipseity-disturbance or self-disorder hypothesis regarding schizophrenia, with focus on some recent and recommended research and theoretical refinements. There is need to expand research and theorizing in several directions-in order to: 1, specify more precisely what is truly distinctive in the schizophrenia spectrum, 2, explore internal structure and explanatory potential of this purported disturbance of minimal- or core-self experience, 3, generate testable hypotheses concerning pathogenetic pathways and psychotherapeutic interventions. Comparative studies can make a crucial scientific contribution. Some recent, exploratory studies are described: published reports were examined for alterations of self-experience in conditions outside the schizophrenia spectrum-mania, psychotic depression, and depersonalization disorder-and in one unusual attitudinal stance: intense introspection (as refined in early 20th century psychological research). Remarkable similarities (e.g., alienation/reification of thoughts and bodily experiences, fading of self and world) as well as some important differences (e.g., absence, outside schizophrenia, of severe erosion of minimal self-experience or real confusion of self and other) in types of self-anomalies were found. These support but also refine the ipseity-disturbance model. Future research should treat self-experience as an independent variable, manipulating and measuring this dimension (in both schizophrenic and non-schizophrenic populations) to study its associations with anomalies of cognition, affect, expression, and neural functioning already identified in schizophrenia. The self-disorder model offers an integrative and dynamic view of schizophrenia congruent with recent trends in cognitive neuroscience and consistent with the heterogeneous, varying, and holistic nature of this enigmatic illness.

The psychiatric interview: validity, structure, and subjectivity

There is a glaring gap in the psychiatric literature concerning the nature of psychiatric symptoms and signs, and a corresponding lack of epistemological discussion of psycho-diagnostic interviewing. Contemporary clinical neuroscience heavily relies on the use of fully structured interviews that are historically rooted in logical positivism and behaviorism. These theoretical approaches marked decisively the so-called “operational revolution in psychiatry” leading to the creation of DSM-III. This paper attempts to examine the theoretical assumptions that underlie the use of a fully structured psychiatric interview. We address the ontological status of pathological experience, the notions of symptom, sign, prototype and Gestalt, and the necessary second-person processes which are involved in converting the patient’s experience (originally lived in the first-person perspective) into an “objective” (third person), actionable format, used for classification, treatment, and research. Our central thesis is that psychiatry targets the phenomena of consciousness, which, unlike somatic symptoms and signs, cannot be grasped on the analogy with material thing-like objects. We claim that in order to perform faithful distinctions in this particular domain, we need a more adequate approach, that is, an approach that is guided by phenomenologically informed considerations. Our theoretical discussion draws upon clinical examples derived from structured and semi-structured interviews. We conclude that fully structured interview is neither theoretically adequate nor practically valid in obtaining psycho-diagnostic information. Failure to address these basic issues may have contributed to the current state of malaise in the study of psychopathology.

Disturbance of Minimal Self (Ipseity) in Schizophrenia: Clarification and Current Status

The assessment of psychopathology in most contemporary research is based squarely on signs and symptoms of disorder, often measured in fairly crude checklist-type fashion. This approach has tended to indicate significant overlap in psychotic and other symptoms across disorders, eg, between schizophrenia and bipolar disorder1 and between psychotic disorders and borderline personality disorder.2 This may partly be the result of the assessment tools and conceptual frameworks being used. By contrast, insights from phenomenological psychiatry and philosophy, focused on disturbed subjectivity,3 indicate that disturbed self-experience or selfhood may underlie and generate many “surface-level” psychotic symptoms, particularly in schizophrenia spectrum disorders.

Phenomenology of Self-Disturbances in Schizophrenia: Some Research Findings and Directions

Phenomenological psychiatry has suffered from a failure to translate its insights into terms specific enough to be applied to psychiatric diagnosis or to be used in contemporary research programs. This difficulty can be understood in light of the well-known tradeoff between reliability and validity. We argue, however, that with sufficient ingenuity, phenomenological concepts can be adapted and applied in a research context. Elsewhere, we have described a phenomenologically oriented conception of schizophrenia as a self- or ipseity-disorder with two main facets: decline in the sense of existing as a subject of awareness (diminished self-affection) and heightened awareness of aspects of experience that would normally remain tacit or presupposed (hyperreflexivity). This approach is consistent with Minkowski, Blankenburg, and Kimura and offers one possible synthesis of their views. Here we describe two areas of empirical research that are congruent with, or actually inspired by, a phenomenological approach emphasizing such disorders of consciousness and self-experience: (1) Phenomenologically oriented, interview studies show that, whereas negative-symptom patients generally deny any diminishment of affect and thinking, they do describe qualitative alterations of experience suggestive of hyperreflexivity and diminished self-affection. (2) Another line of research suggests that the early detection of schizophrenic symptoms may be enhanced by adopting a phenomenological approach.

Cognitive-behavioral therapy for schizophrenia: a critical evaluation of its theoretical framework from a clinical-phenomenological perspective.

Background: Cognitive-behavioral therapy (CBT) has played an increasingly important role in psychotherapy for schizophrenia since the 1990s, but it has also encountered many theoretical and practical limitations. For example, methodologically rigorous meta-analyses have recently found only modest overall effect sizes of CBT treatment, and therefore questions have emerged about forwhat and for whom it actually works. Method: The focus of the present paper is to elucidate the theoretical assumptions underlying CBT for schizophrenia and to examine their consistency with abnormalities of experience and self-awareness frequently reported by schizophrenia patients and systematically studied in phenomenological psychopathology from the beginning of the 20th century. Results: We argue that a strong theoretical emphasis on cognitive appraisals with only subsidiary attention devoted to affective and behavioral processes - as is characteristic of many forms of CBT - cannot satisfactorily account for the complex subjective experiences of schizophrenia patients. We further argue that certain theoretical strategies widely employed in CBT to explore and explain mental disorders, which involve atomization and, at times, a reification of mental phenomena, can be problematic and may result in a loss of explanatory potential. Finally, we provide a detailed account of how negative symptoms and delusions are conceptualized in CBT and consider the question of how these concepts fit the actual phenomenology of schizophrenia. Conclusion: We suggest that further advancement of CBT theory and practice can benefit from a dialogue with phenomenological psychiatry in the search for effective psychotherapeutic strategies for schizophrenia patients.

Does disturbance of self underlie social cognition deficits in schizophrenia and other psychotic disorders

Aim: Although the different approaches to psychosis research have made significant advances in their own fields, integration between the approaches is often lacking. This paper attempts to integrate a strand of cognitive research in psychotic disorders (specifically, social cognition research) with phenomenological accounts of schizophrenia and other psychotic disorders.

The Phenomenological Model of Psychotic Vulnerability and Its Possible Implications for Psychological Interventions in the Ultra-High Risk (‘Prodromal’) Population

The early intervention movement for treatment of schizophrenia and other psychotic disorders has extended to include pharmacological and psychological treatment of putatively prodromal (or ‘ultra-high risk’) patients. The psychotherapy that has been trialed to date is cognitive-behaviour therapy (CBT), due to its apparent success with patients with established psychotic disorder and its current popularity as a therapeutic modality. This paper presents phenomenological models of psychotic, particularly schizophrenic, vulnerability, which emphasise a disturbed basic sense of self (ipseity) and intersubjectivity. We argue that these phenomenological models indicate that CBT may not be the most suitable therapy for prodromal patients, and may even be counterproductive. A central element of this argument is that CBT’s emphasis on cognitive reflection and challenging may encourage a core pathological process in these patients (hyper-reflexive awareness). The paper explores alternatives for psychotherapy that emerge from phenomenological accounts of psychosis, while recognising the paradoxical aspects of psychotherapy with these patients. These alternatives include strategies that provide an intersubjective space where patients can evolve a more robust pre-reflective self-awareness (first-person perspective), second-person perspective and experience of trustworthy relationships when encountering others, empathic attunement afforded by the phenomenological approach’s sensitivity to psychotic experience, and strategies that encourage a form of immersion or absorption in present activity, including mindfulness and creative ‘flow’. We also suggest the possible value of combining therapeutic modalities (even ones that may seem contradictory) and of the need to empirically test therapeutic strategies other than CBT in the ultra-high risk population.

Phenomenological and neurocognitive perspectives on delusions: A critical overview

There is considerable overlap between phenomenological and neurocognitive perspectives on delusions. In this paper, we first review major phenomenological accounts of delusions, beginning with Jaspers’ ideas regarding incomprehensibility, delusional mood, and disturbed “cogito” (basic, minimal, or core self‐experience) in what he termed “delusion proper” in schizophrenia. Then we discuss later studies of decontextualization and delusional mood by Matussek, changes in self and world in delusion formation according to Conrads notions of “apophany” and “anastrophe”, and the implications of ontological transformations in the felt sense of reality in some delusions. Next we consider consistencies between: a) phenomenological models stressing minimal‐self (ipseity) disturbance and hyperreflexivity in schizophrenia, and b) recent neurocognitive models of delusions emphasizing salience dysregulation and prediction error. We voice reservations about homogenizing tendencies in neurocognitive explanations of delusions (the “paranoia paradigm”), given experiential variations in states of delusion. In particular we consider shortcomings of assuming that delusions necessarily or always involve “mistaken beliefs” concerning objective facts about the world. Finally, we offer some suggestions regarding possible neurocognitive factors. Current models that stress hypersalience (banal stimuli experienced as strange) might benefit from considering the potential role of hyposalience in delusion formation. Hyposalience – associated with experiencing the strange as if it were banal, and perhaps with activation of the default mode network – may underlie a kind of delusional derealization and an “anything goes” attitude. Such an attitude would be conducive to delusion formation, yet differs significantly from the hypersalience emphasized in current neurocognitive theories.