A Disappearing Heritage

The Clinical Core of Schizophrenia

Josef Parnas

Disclosures

Schizophr Bull. 2011;37(6):1121-1130. 

In This Article

The Structure of Subjectivity: Self in Schizophrenia

A brief articulation of the structure of subjectivity or consciousness is now needed to grasp the notion of the disorders of the self in the core Gestalt of schizophrenia. The concept of self can be addressed at different levels of reality and abstraction. Here, we are concerned with its basic universal experiential aspects.[28] This ordinary phenomenological notion of the self means that we live our conscious life in the first person perspective, as a self-present, single, temporally persistent, embodied, and bounded (demarcated) entity, who is the subject of his experiences.[29] That these basic structural aspects of self-hood may become altered or even shattered in schizophrenia was noted already at the very conception of the notion the illness. Bleuler[16] considered self-disorders as belonging to the "complex fundamental symptoms" (affecting the person). He wrote that the patient's ego tends to undergo "the most manifold alterations," eg, splitting and loss of the directedness of thinking. "A very intelligent person needs hours of strenuous effort to find her own ego for a few brief moments"; "patients cannot catch up with themselves" or they "have lost their individual self"[16] (p143). Gruhle[30] talked about the disordered selfhood as reflecting a specific existential tonality of being in schizophrenia. Kraepelin[31] considered "loss of inner unity of consciousness" and "devastation of the will" (orchestra without a conductor) as the core features defining schizophrenia. Both notions imply a "devastation" of the self because it is the self that imposes a sense of unity on the multitude of mental contents. Right now, while I am typing this text into my notebook, the unity of my ongoing visual, tactile, auditory, etc. experiences is brought about through their shared feature or character of being my experiences. They are all given to me as their subject, making them inherent in one (my) field of awareness.[28] Kurt Schneider noted that:

(C)ertain disturbances of self-experience show the greatest degree of schizophrenic specificity. Here we refer to those disturbances of first-personal-givenness(Ich-heit) or mineness (Meinhaftigkeit) which consist of one's own acts and states not being experienced as one's own,[32] (p58).

The issue of disorders of self was widely addressed in psychopathological literature,[19,27,30,33,34] both at a clinical and a theoretical level. The view of autism, as a manifestation of the fundamental changes of subjectivity came to mark the final articulation of European view on the "whatness" of schizophrenia. Thus, the ICD-8/9 Glossary[35] defines the clinical core of schizophrenia as a change in the patient's structure of subjectivity: it is "the fundamental disturbance of personality (self), (which) involves its most basic functions, those that give the normal person his feeling of individuality, uniqueness, and self-direction" (p27; here, "personality in its most basic functions" refers to the structure of the person or the self).

More recently, 2 Scandinavian studies have independently rediscovered the disorders of self-experience in the schizophrenia spectrum conditions, a research inspired by extensive semistructured interviews with young first-admitted patients with beginning schizophrenia. The patients typically complained of feeling ephemeral, not really existing, lacking a basic identity core, feeling profoundly different from others, and not fully belonging to the shared world. This work was systematically replicated on 151 first admission cases followed up for 5 years[36–38] and on a large, diagnostically stratified sample at genetic risk for schizophrenia.[39]

It is important to emphasize that we are dealing here with the anomalies of experience and not with delusions or hallucinations. Self-disorders occur both in schizophrenia and schizotypal disorders. They comprise a pervasively diminished or insecure sense of existing as an embodied self-present subject, various distortions of first person perspective, eg, with anonymization of the field of awareness or deficient "mineness" ("my thoughts have no respect for me"), various alienations in the stream of cognition, spatialization of mental contents, eg, thoughts being experienced as located extended objects ("my thoughts always press from behind mainly here, on the left"), feelings of disembodiment, inadequate ego-demarcation, and, very importantly, lack of attunement to and inability of immersion in the world ("I only live in my head"). Isolation seems here to be more solipsistic, "growing from within," ie, constitutive, rather than operating only as a defensive withdrawal. Bleulerian "retreat to the inner world" is more adequately seen as a constitution of a different, ie, "private world".

The inability to project oneself forth in the world (…), the tendency to disperse oneself in the flux of subjectivity, the disproportion between the "inside" and the "outside" of existence, constitute a constant infrastructure of consciousness (…) in schizophrenia.[40] (p167)

Self-disorders are persisting and often pervasive (trait) phenomena, whose onset usually dates to early adolescence or even childhood. The schizophrenia spectrum patients may also experience a variety of anomalies in all perceptual modalities.[41]

Comments

3090D553-9492-4563-8681-AD288FA52ACE

processing....