Mads Gram Henriksen

Disordered Self in the Schizophrenia Spectrum: A Clinical and Research Perspective

Learning ObjectivesAfter participating in this activity, learners should be better able to:1. Assess anomalous self-experience as a core feature of schizophrenia spectrum disorders.2. Evaluate current and historical research regarding disorders of self-experience in schizophrenia. AbstractThis article explores the phenomenological and empirical rediscovery of anomalous self-experience as a core feature of the schizophrenia spectrum disorders and presents the current status of research in this field. Historically, a disordered self was considered to be a constitutive phenotype of schizophrenia. Although the notion of a disordered self has continued to appear occasionally over the years—mainly in the phenomenologically or psychodynamically oriented literature—this notion was usually considered as a theoretical construct rather than as referring to concretely lived anomalous experiences. Empirical research on the disorders of self-experience in schizophrenia can be traced back to the US-Denmark psychopathological collaboration in the well-known adoption and high-risk studies, which aimed at identifying trait or phenotypic vulnerability features. This research was later followed by clinical work with first-admission schizophrenia patients. We offer clinical descriptions of anomalous self-experience and outline the phenomenological structures of subjectivity that are needed for grasping the nature of these anomalous experiential phenomena. What appears to underlie these experiences is an instability of the first-person perspective that threatens the basic experience of being a self-coinciding, embodied, demarcated, and persisting subject of awareness. We summarize a series of empirical studies targeting self-experience in schizophrenia performed prior to and after the construction of a phenomenologically oriented psychometric instrument for assessing anomalies of self-experience, the Examination of Anomalous Self-Experience (EASE). These empirical studies support the classic clinical intuition that anomalous self-experiences form a central phenotype of schizophrenia. Implications for diagnosis and research are briefly discussed.

Clinical Manifestations of Self-disorders and the Gestalt of Schizophrenia

Anomalies of self-experience (self-disorders) constitute crucial phenotypes of the schizophrenia spectrum. The following qualitative study demonstrates a variety of these core experiential anomalies. From a sample of 36 first-admitted patients, all of whom underwent a comprehensive psychiatric evaluation, including the EASE scale (Examination of Anomalous Self-Experience), 2 schizophrenia patients were selected for detailed psychopathological presentation and discussion. The vignettes provide prototypical examples of what has been termed self-disorders in schizophrenia, ie, pervasive and enduring (mainly) trait phenomena which constitute essential aspects of the spectrum.

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.

The Pathogenesis of Auditory Verbal Hallucinations in Schizophrenia: A Clinical–Phenomenological Account

Although hallucinations are among the most studied psychiatric symptoms, their pathogenesis remains largely unknown and their experiential complexities are rarely accounted for. In schizophrenia, auditory verbal hallucinations are by far the most frequently reported type of hallucination. In this study, we explore verbal hallucinations in schizophrenia and we argue that these are best understood not as abnormal perceptions, but as cognitive phenomena arising from a partial dissolution of certain structures of self-consciousness. Consistent with recent empirical and conceptual studies in phenomenological psychiatry, we claim that specific alterations of self-awareness tend to precede the emergence of verbal hallucinations in schizophrenia. We illustrate these altered states of self-awareness in three detailed case vignettes of hallucinating schizophrenia spectrum patients. We propose a clinical–phenomenological account of the pathogenesis of verbal hallucinations in schizophrenia, suggesting that pathological changes in the experience of space and morbid objectification of inner speech may lead to crystalized verbal hallucinations.

Genetics of Schizophrenia: Overview of Methods, Findings and Limitations

Genetics constitute a crucial risk factor to schizophrenia. In the last decade, molecular genetic research has produced novel findings, infusing optimism about discovering the biological roots of schizophrenia. However, the complexity of the object of inquiry makes it almost impossible for non-specialists in genetics (e.g., many clinicians and researchers) to get a proper understanding and appreciation of the genetic findings and their limitations. This study aims at facilitating such an understanding by providing a brief overview of some of the central methods and findings in schizophrenia genetics, from its historical origins to its current status, and also by addressing some limitations and challenges that confront this field of research. In short, the genetic architecture of schizophrenia has proven to be highly complex, heterogeneous and polygenic. The disease risk is constituted by numerous common genetic variants of only very small individual effect and by rare, highly penetrant genetic variants of larger effects. In spite of recent advances in molecular genetics, our knowledge of the etiopathogenesis of schizophrenia and the genotype-environment interactions remain limited.

Self-Disorders in Schizophrenia

The notion of disordered self as the core, trait-phenotypic disturbance of schizophrenia was ventilated in nearly all foundational texts on schizophrenia, and it is strongly supported by recent empirical studies. In this chapter, we introduce the reader to a variety of clinical manifestations of self-disorders in single, comprehensive case story, which we subsequently analyze in the light of contemporary phenomenological research. We also briefly address the psychopathological core that appears to underlie the various manifestations of self-disorders. Moreover, we provide a dense overview of the results from empirical studies, and we discuss the adequate way of assessing self-disorders in the psychiatric interview. We conclude that self-disorders are crucial elements in the psychopathology of schizophrenia and that they may aid the understanding of our patients and their experiential life, play a significant role in diagnostic and differential diagnostic procedures, and offer vital resources for a more phenomenologically informed psychotherapy for schizophrenia.

Self-Disorders, Neurocognition and Rationality in Schizophrenia: A Preliminary Study

Background/Aims: Although the very idea that the generative disorder in schizophrenia is a disturbance of the self is as old as the schizophrenia concept itself, empirical studies have only recently emerged, documenting that anomalous self-experiences (i.e. self-disorders, SDs) aggregate in schizophrenia spectrum disorders but not in other mental disorders. The aim of this study is to explore potential associations between SDs, neurocognitive performance, rationality and IQ in patients with schizophrenia. Methods: The sample comprises 31 patients diagnosed with schizophrenia (DSM-IV). All patients underwent comprehensive evaluation. SDs were assessed with the Examination of Anomalous Self-Experience scale. Neurocognitive performance was measured with 4 PC-implemented subtests from the Cambridge Neuropsychological Test Automated Battery. Rationality was measured using syllogism tests. The IQ was indexed by a summary score of 4 IST-2000-R computerized subtests. Results: No correlation was found between SDs and neurocognitive performance or between SDs and IQ. SDs were found to correlate with rationality. Neurocognitive performance correlated with rationality, and both correlated with IQ, respectively. Conclusions: The lack of correlation between SDs and neurocognitive performance is consistent with the results from the only previous study exploring this issue, suggesting that SDs depict something essential to schizophrenia, whereas neurocognitive impairment does not. The correlation between SDs and rationality indicates that the syllogism tests reflect something central for schizophrenia, but the result needs further corroboration from larger, empirical studies.

Panic, Self-Disorder, and EASE Research: Methodological Considerations

cusing also on schizotypal traits, would be necessary. For example, one study demonstrated that healthy subjects with few schizotypal traits (not warranting a clinical diagnosis) score higher on self-disorders than healthy subjects completely free of schizotypal features [9] . In the study by Madeira et al. [1] , diagnoses were allocated by treating clinicians, using the MINI, and the patients were not diagnosed by a thorough in-depth psychopathological research assessment. In fact, European clinicians practically never use the diagnosis of schizotypal disorder with the few exceptions of university clinics with a long track record of research on schizophrenia spectrum disorders [10] . The use of the MINI is not a safeguard – on the contrary, as is explicitly stated in the MINI 5.0.0 manual (July 1, 2006): “This program is not designed or intended to be used in the place of a full medical and psychiatric evaluation by a qualified licensed physician-psychiatrist.” Moreover, the MINI does not address personality disorders, including DSM schizotypal disorder. Thus, with respect to the sample, we are left with a group of chronic patients, whose diagnostic profile is basically unclear and who were certainly not screened for schizotypal features. If we look at the self-disorders scored in this sample, it is peculiar that none of the patients was found to be psychotic or schizotypic, given the fact that all experiential schizotypal items are present in the EASE and several patients had first-rank symptoms (EASE item 1.7.3) or delusional Isplit (EASE item 2.7.4). Madeira et al. [1] report high levels of EASE-measured self-disorders in a sample of chronic, treatmentresistant, panic disorder (PD) patients without a comorbid diagnosis ( n = 47) and compared to populationdrawn controls ( n = 47). They motivate their study by considering self-disorders as a potentially “transdiagnostic” phenotype and seem basically to show that their patient group exhibits self-disorder scores on a similar level as that reported in schizophrenia spectrum patients [2–6] . Our commentary is prompted by a concern about the potential confusion the study [1] may bring about in this research field. Instead of perceiving self-disorders as a transdiagnostic feature, as the authors seem to do, it is perhaps more appropriate to consider anxiety and panic as transdiagnostic features. DSM-5 explicitly states: “Panic disorder infrequently occurs in clinical settings in the absence of other psychopathology” [7] . Several studies have shown that PD patients show comorbidity in 80% of cases and that the PD diagnosis massively increases the odds ratio (OR = 35.66) for comorbid psychosis [8] . In other words, the sample in Madeira et al. [1] is peculiar with regard to the total absence of comorbidity. Another crucial issue concerns the diagnostic assessment of this sample. If the motivation of the study was to explore the presence of self-disorders beyond the schizophrenia spectrum, then a systematic and comprehensive, in-depth psychopathological research assessment of the study population, foReceived: March 9, 2017 Accepted after revision: March 16, 2017 Published online: April 11, 2017

Embodiment and Affectivity in Moebius Syndrome and Schizophrenia: A Phenomenological Analysis

In this comparative study, Joel Kreuger and Mads Gram Henriksen examine experiential disruptions of embodiment and affectivity in Moebius Syndrome and schizophrenia. They suggest that using phenomenological resources to explore these experiences may provide a better understanding of what it’s like to live with these conditions, and that such an understanding may have significant therapeutic value. Additionally, they suggest that this sort of phenomenologically informed comparative analysis can shed light on the importance of embodiment and affectivity for the constitution of a sense of self and interpersonal relatedness in normal conditions.

Intersubjectivity and Psychopathology in the Schizophrenia Spectrum: Complicated We, Compensatory Strategies, and Self-Disorders

Recent studies in phenomenological psychopathology emphasize the importance of intersubjectivity for our understanding of schizophrenia. Yet, the central role of the “we” in social experience and engagement is largely absent from this literature. Our study explores the relation between psychopathology and intersubjectivity in the schizophrenia spectrum through the prism of the “we.” First, we explore the role of intersubjectivity in the current schizophrenia spectrum definitions and discuss the main contemporary research trends. Second, we recollect some of the classical accounts of schizophrenia, which offer a different perspective on the pervasive and often persistent intersubjective difficulties in these conditions. Third, capitalizing on recent advances in collective intentionality studies, we present and discuss a conceptual framework of the “we” and of how the “we” may be disrupted in schizophrenia. Through this framework and with the use of clinical vignettes, we elicit 3 compensatory strategies, which, we suggest, reflect a fragile sense of “we” in the schizophrenia spectrum, i.e. (i) positive withdrawal, (ii) imposing a goal-oriented, spatiotemporal structure on intersubjective engagement, and (iii) preferring social activities with a clear attribution of social roles and rules. Finally, we discuss the relation between anomalous self-experiences (i.e. self-disorders) and the complicated “we.”