A self-disorder, also called ipseity disturbance, is a psychological phenomenon of disruption or diminishing of a person's minimal self – the fundamental sense that one's experiences are truly one's own. People with self-disorder feel that their internal experiences are actually external; for example, they may experience their own thoughts as coming from outside themselves, whether in the form of true auditory hallucinations or merely as a vague sense that their thoughts do not belong to them.
The concept resembles the basic symptoms of schizophrenia, but the term itself was introduced in the early 2000s together with the Examination of Anomalous Self-Experience (EASE) scale, which is used to measure the presence and severity of self-disorder.[6] The concept is associated with the theoretical approach to psychology known as phenomenology.[2]
The minimal (or basic) self has been likened to a "flame that enlightens its surroundings and thereby itself."[2] The sense of minimal self refers to the very basic sense of having experiences that are one's own; it has no properties, unlike the extended self, which is composed of properties such as the person's identity, the person's narrative, their likes and dislikes, and other aspects that are the result of reflection on one's self. The minimal self, however, refers to the "mine-ness" or "given-ness" of experience, that the experiences are that of the person having them in that person's stream of consciousness. These experiences that are part of the minimal self are normally "tacit" and implied, requiring no reflection on the part of the person experiencing to know that the experience is theirs. The minimal self cannot be further elaborated and normally one cannot grasp it upon reflection.[2] The minimal self goes hand-in-hand with immersion in the shared social world, such that "[t]he world is always pregiven, ie, tacitly grasped as a self-evident background of all experiencing and meaning." This is the self-world structure.[7]
De Warren gives an example of the minimal self combined with immersion in the shared social world: "When looking at this tree in my backyard, my consciousness is directed toward the tree and not toward my own act of perception. I am, however, aware of myself as perceiving this tree, yet this self-awareness (or self-consciousness) is not itself thematic."[8] The focus is normally on the tree itself, not on the person's own act of seeing the tree: to know that one is seeing the tree does not require an act of reflection.[citation needed]
In the schizophrenia spectrum disorders, the minimal self and the self-world structure are "constantly challenged, unstable, and oscillating," causing anomalous self-experiences known as self-disorders. These involve the person feeling as if they lack an identity, as if they are not really existing, that the sense of their experiences being their own (the "mine-ness" of their experiential world) is failing or diminishing, as if their inner experiences are no longer private, and that they don't really understand the world. These experiences lead to the person engaging in hyper-reflectivity, or abnormally prolonged and intense self-reflection, to attempt to gain a grasp on these experiences, but such intense reflection may further exacerbate the self-disorders. Self-disorders tend to be chronic, becoming incorporated into the person's way of being and affecting "how" they experience the world and not necessarily "what" they experience. This instability of the minimal self may provoke the onset of psychosis.[7][9]
Similar phenomena can occur in other conditions, such as bipolar disorder and depersonalization derealization disorder, but Sass's (2014) review of the literature comparing accounts of self-experience in various mental disorders shows that serious self-other confusion and "severe erosion of minimal self-experience" only occur in schizophrenia;[10] as an example of the latter, Sass cites the autobiographical account of Elyn Saks, who has schizophrenia, of her experience of "disorganization" in which she felt that thoughts, perceptions, sensations, and even the passage of time became incoherent, and that she had no longer "the solid center from which one experiences reality", which occurred when she was 7 or 8 years old.[11] This disturbance tends to fluctuate over time based on emotions and motivation, accounting for the phenomenon of dialipsis in schizophrenia, where neurocognitive performance tends to be inconsistent over time.[10]
The disturbance of the minimal self may manifest in people in various ways, including as a tendency to inspect one's thoughts in order to know what they are thinking, like a person seeing an image, reading a message, or listening closely to someone talking (audible thoughts; or in German: Gedankenlautwerden). In normal thought, the "signifier" (the images or inner speech representing the thought) and the "meaning" are combined into the "expression", so that the person "inhabits" their thinking, or that both the signifier and the meaning implicitly come to mind together; the person does not need to reflect on their thoughts to understand what they are thinking. In people with self-disorder, however, it is frequently the case that many thoughts are experienced as more like external objects that are not implicitly comprehended. The person must turn their focus toward the thoughts to understand their thoughts because of that lack of implicit comprehension, a split of the signifier and the meaning from each other, where the signifier emerges automatically in the field of awareness but the meaning does not. This is an example of the failing "mine-ness" of the experiential field as the minimal self recedes from its own thoughts, which are consigned to an outer space. This is present chronically, both during and outside of psychosis, and may represent a middle point between normal inner speech and auditory hallucinations, as well as normal experience and first-rank symptoms.[12]
They may also experience uncontrolled multiple trains of thought with different themes simultaneously coursing through one's head interfering with concentration (thought pressure) or often feel they must attend to things with their full attention in order to get done what most people can do without giving it much thought (hyper-reflectivity), which can lead to fatigue.[6][2]
The EASE is a semi-structured interview that attempts to capture the extent of the mainly non-psychotic self-disorders experienced by the person. It is divided into 5 broad sections:
Cognition and stream of consciousness, which covers disturbances in the flow of thoughts and experiences, and includes such self-disorders as "thought pressure", an experienced chaos of unrelated thoughts, "loss of thought ipseity", a sense as if the person does not own their thoughts (but not to the level of psychosis), and "spatialization of experience", which is where the person experiences their thoughts as if they occurred within a space.
Self-awareness and presence, which deals with dissociative experiences of the self and world as well as a tendency toward intense reflection, in addition to a declining understanding of how to interact with others and the world called "perplexity" or "lack of natural evidence."
Bodily experiences, which deals with alienating experiences of the body as well as with "mimetic experiences", the sense of a person that if they move, pseudo-movements of other, unrelated objects are experienced
Demarcation/transitivism, which covers specific disturbances in the person's ego boundaries such as the person confusing their own thoughts, ideas, and feelings for that of their interlocutor.
Existential reorientation, which refers to changes in the person's experience of the world that reflect the effect of self-disorders on the person's worldview.
A large number of these items have affinities with the basic symptoms.[6]
The EASE, and pre-EASE studies attempting to assess basic self-disturbance, has been found in studies to discriminate between people on the schizophrenia spectrum, and those with psychotic bipolar disorder or borderline personality disorder. The EASE has been found to have good reliability, meaning that when 2 clinicians do the assessment, they draw roughly the same conclusions.[2] The items on the EASE were compared against the accounted experiences of depersonalization disorder, finding many affinities, but also differences, reflecting namely the failing sense of "mine-ness" of the experiential world and a tendency to confuse the self with the world, others, or both.[13]
Thoughts that are not semantically related to the main line of thinking pop up and interfere with it; these thoughts are generally irrelevant and unimportant.
1.2 Loss of thought ipseity
Thoughts appear strange in that they do not seem as if they originate from the self; the person is rationally aware that these thoughts are theirs.
1.3 Thought pressure
Many thoughts appearing simultaneously or in rapid succession that lack a common theme, which the person feels they cannot control.
1.4 Thought block
The train of thought comes to a halt.
1.4.1 Blocking
The thought becomes lost and inaccessible and no new thought appears in its place.
1.4.2 Fading
The thought slowly fades away with no new thought appearing.
1.4.3 Fading combined with simultaneous or successive thought interference
The thought slowly fades away while a new thought begins to appear.
1.5 Silent thought echo
A thought which is not perceptualized is repeated or doubled.
1.6 Ruminations-obsessions
Persistence or recurrence of thoughts.
1.6.1 Primary ruminations
Tendency to ruminate with no underlying reason.
1.6.2 Secondary ruminations
Tendency to ruminate secondary to another issue, such as perplexity.
1.6.3 True obsessions
Recurring thoughts that are not macabre and which the person attempts to resist.
1.6.4 Pseudo-obsessions
Recurring thoughts that tend to have violent, sexual, or otherwise aggressive content that are generally not resisted by the person. In the ICD-10's definition of schizotypal disorder these are called "obsessive ruminations", and they tend to play out like movies or series of projections in a space internal to the person's mind, located perhaps "on an inner screen" or "behind [their] eyes", that they passively watch and may also inspect.[14]
1.6.5 Compulsions
Rituals in relation to ruminations or obsessions.
1.7 Perceptualization of inner speech or thought
Thoughts acquire perceptual qualities, which may appear to occur in the head or outside the person (hallucinations).
1.7.1 Internal
The person experiences these perceptions as occurring inside the head.
1.7.2 Equivalents
Thoughts appear as written text.
1.7.3 Internal as a psychotic first-rank symptom
Person believes the thoughts are so loud that they can be heard by others.
1.7.4 External
Person experiences hallucinations, which may seem to repeat their thoughts.
1.8 Spatializaton of experience
Internal experiences such as thoughts appear as if they occurred inside an internal space; the person may experience them as being like physical objects appearing in that space.
1.9 Ambivalence
Difficulty deciding between 2 or more insignificant options.
1.10 Inability to discriminate modalities of intentionality
Person has difficulty telling the difference between perceptions and imaginations and between true memories and dreams.
1.11 Disturbance of thought initiative or thought intentionality
Difficulty initiating and organizing goal-directed activities.
1.12 Attentional disturbances
(see subtypes)
1.12.1 Captivation of attention by a detail in the perceptual field
Person is drawn to aspects of the environment which are hard to divert attention away from, even though the person has no particular interest in those details.
1.12.2 Inability to split attention
The person cannot do 2 or more activities at the same time which use different senses.
1.13 Disorder of short-term memory
Difficulty keeping things in mind for a short period of time experienced as a tendency to forget things from the beginning as the person continues, such as in reading a story.
1.14 Disturbance in experience of time
Change in the flow of time, not including changes in flow speed caused by boredom or pleasure, or regarding past vs. future.
1.14.1 Disturbance in the subjective experience of time flow
Time seems to speed up, slow down, stand still, or become fragmented.
1.14.2 Disturbance in the existential time
The future is blocked and existence seems to be dominated by either the present or the past.
1.15 Discontinuous awareness of own action
Break in awareness of own actions.
1.16 Discordance between intended expression and the expressed
The person experiences their expression as being uncontrollable, distorting the meaning of what the person is actually trying to say.
1.17 Disturbance of expressive language function
The person experiences difficulty in mobilizing the words needed to express themselves.
Domain 2: Self-awareness and presence
Symptom
Description
2.1 Diminished sense of basic self
Feelings as if one is, for example, ephemeral, non-existent, profoundly different from others (but unable to sufficiently elaborate on this), or that one must agree with others; this has occurred chronically since at least adolescence.
2.1.1 Childhood onset
Onset was before puberty.
2.1.2 Adolescence onset
Onset was in adolescence.
2.2 Distorted first-person perspective
There are at least 3 subtypes.
2.2.1
Person feels as if their experiences aren't their own, at least briefly, or as if they were a mere inanimate object.
2.2.2
Person feels an incredible distance between the self and experience, resulting in intense and involuntary constant or recurring self-monitoring.
2.2.3
Person feels as if the self were located at a specific point in space, or perhaps as if it were a physical object, or both.
2.3 Other states of depersonalization
Sense of alienation from self or one's own experience.
2.3.1 Melancholiform depersonalization
Melancholic mood change from which the person feels alienated.
2.3.2 Unspecified depersonalizaton
Other depersonalization
2.4 Diminished presence
An increased distance from being affected by the world that is experienced by the person as originating from within the self; this is experienced as an affliction by the person.
2.4.1 Specified
Increasing distance from the world experienced as apathy towards specific events.
2.4.2 Unspecified
Sense of barrier between self and world that cannot be furthered specified by the person.
2.4.3 Including derealization or perceptual change
Where the sense of barrier results in a change in world perception (e.g. sense of fogginess) or is accompanied by derealization.
2.5 Derealization
The world appears as strange, alien, unreal, or changed.
2.5.1 Fluid (global) derealization
The world seems to lose its color or become lifeless, or there is some other diminution of the qualities of the world.
2.5.2 Intrusive derealization
Things in the world seem much more intrusive than normal, which strongly affect the person emotionally.
2.6 Hyperreflectivity; increased reflectivity
Tendency to engage in excessive reflection of matters involving the self or other things hindering the sense of being able to live carefree or spontaneously; person will engage in intense reflection while engaged in activity (called also "simultaneous introspection" in Japanese psychopathology).
2.7 I-split
Sense that the self does not exist as a unified whole beyond having a multifaceted personality.
2.7.1 I-split suspected
When person's comments hint at I-split.
2.7.2
Person reports non-psychotic experience of I-split.
2.7.3
Person reports non-psychotic experience of I-split that is experienced in a way that the different pieces of self exist at different points in space like physical objects.
2.7.4
Person reports delusional experience of I-split.
2.8 Dissociative depersonalization (out of body experience)
Person experiences the self as if it were outside the body.
2.8.1
Person feels as if this is occurring, without hallucinating.
2.8.2
Person experiences this as a dissociative hallucination.
2.9 Identity confusion
Person feels as if they were another person.
2.10 Sense of change in relation to chronological age
Feeling as if the person were very much younger or older than they really are.
2.11 Sense of change in relation to gender
(see subtypes)
2.11.1
Person worries that they might be gay.
2.11.2
Person is confused about their sex or feels as if they were the opposite sex.
2.12 Loss of common sense/perplexity/lack of natural evidence
Person is confused about the meaning of what people normally understand implicitly and may spend a lot of time wondering why, say, the sky is blue or 2+2=4; or person may follow extremely rigid schemas that come across as bizarre to others ("morbid rationalism") or may have a tendency to obsess about the spatial or geometric aspects of the world ("geometrism").
2.13 Anxiety
(see subtypes)
2.13.1 Panic attacks with autonomous symptoms
Panic accompanied by multiple autonomic symptoms including labored breathing, heart racing, chest pain, or a sense of choking.
2.13.2 Psychic-mental anxiety
Feeling of anxiety without autonomic symptoms.
2.13.3 Phobic anxiety
Anxiety triggered by specific fears (e.g. agoraphobia).
2.13.4 Social anxiety
Anxiety caused by social situations.
2.13.5 Diffuse, free-floating, and pervasive anxiety
Intense, constant anxiety.
2.13.6 Paranoid anxiety
Anxiety triggered by paranoid fears.
2.14 Ontological anxiety
Pervasive anxiety experienced by person over their own existence that causes them to be more interested in survival than in self-realization; it can involve a sense as if something ominous were approaching, a sense of being exposed to others, or some other fear of violation of their own existence.
2.15 Diminished transparency of consciousness
A sense that one is blocked from clearly perceiving the contents of consciousness which is not secondary to something else (e.g. thought pressure, organic brain disorder, or clinical depression).
2.16 Diminished initiative
Pervasive difficulty initiating goal-directed activity that is not secondary to, for example, clinical depression.
2.17 Hypohedonia
Pervasive and recurring diminished capacity for pleasure.
2.18 Diminished vitality
Sense of diminishment of one's vital energy that is not secondary to, for example, clinical depression.
2.18.1 State-like
Experienced only episodically.
2.18.1 Trait-like
Experienced chronically.
Domain 3: Bodily experiences
Symptom
Description
3.1 Morphological change
Sensations or perceptions as if parts of the body or the entire body has changed size or shape.
3.1.1
Due to paroxysmal sensations.
3.1.2
Due to perception.
3.2 Mirror-related phenomena
Frequently looking at mirrors or avoiding mirrors, or otherwise feeling as if the shape of the face has changed when looking in a mirror.
3.2.1
The person only looks in the mirror to see if their face has changed, but perceives no change.
3.4 Psychophysical misfit and psychophysical split
The body feels as if it does not fit (but not simply because the person dislikes their appearance) or a feeling as if the body and mind do not go together.
3.5 Bodily disintegration
Feeling as if the body is falling to pieces.
3.6 Spatialization of bodily experiences
Feeling as if parts of the body were no longer a medium for action but as if they were simply standalone physical objects, or feeling as if one can feel body parts that one normally cannot feel.
3.7 Cenesthetic experiences
Various unusual bodily sensations, including feelings of numbness, electrical sensations, and thermal sensations.
3.8 Motor disturbances
(see subtypes)
3.8.1 Pseudo-movements of the body
Person feels as if a part of the body is moving, but it actually is not.
3.8.2 Motor interference
Movements of the body intended by the person are derailed, moving in a way not intended by the person.
3.8.3 Motor blocking
Person feels unable to move a body part.
3.8.4 Sense of motor paresis
Usually temporary sense of weakness in one or more limbs, which can interfere with the person's physical movements (such as grasping an object).
3.8.5 Desautomation of movement
Normally automatic or partially automatic physical activities that are carried out on a daily basis or frequently, such as brushing one's hair or riding a bike, can no longer be so, causing the person to have to concentrate and guide each aspect of their movement.
3.9 Mimetic experiences
Pseudo-movements of other objects and people are experienced as if there were a connection to the person's own actions.
Domain 4: Transitivism/demarcation
Symptom
Description
4.1 Confusion with the other
Person confuses their thoughts, feelings, and other aspects with their interlocutor, or otherwise feels invaded or intruded upon by their interlocutor (but cannot explain why this is so).
4.2 Confusion with one's own specular image
Person confuses themselves with their reflection, such as when they are looking in a mirror.
4.3 Threatening bodily contact
(see subtypes)
4.3.1
Person feels threatened by being close to or in contact with another person not because of paranoia or suspicion.
4.3.2
Person feels annihilated when in close contact with another person.
4.4 Passivity mood
Mood-like feeling of being at the mercy of the world, with the person feeling restrained.
4.5 Other transitivistic phenomena
Other feelings as if not properly demarcated from other people and the world.
Domain 5: Existential reorientation
Symptom
Description
5.1 Primary self-reference phenomena
Person feels as if outside events are connected to themselves which cannot be explained by any more primary psychopathology.
5.2 Feeling of centrality
Brief feeling as if being at the center of all existence.
5.3 Feeling as if the subject's experiential field is the only extant reality
Person feels as if only things they are perceiving exist, such that it feels as if things cease to exist when the person looks away, for example.
5.4 "As if" feelings of extraordinary creative power, extraordinary insight into hidden dimensions of reality, or extraordinary insight into own mind or the mind of others.
person experiences a sense as if they possess insight most other people do not.
5.5 "As if" feeling that the experienced world is not truly real, existing, as if it was only somehow apparent, illusory, or deceptive
An example includes feeling as if the person were in a movie.
The EAWE is the companion interview to the EASE that focuses on the person's experiences with the world, rather than with the self. There are 6 domains:
Space and objects, which deals with the person's experience with space and physical objects, with disorders including hallucinations, distortions of spatial relationships, and experiences of seeing the same object in multiple ways at the same time (called "contamination" on the Rorschach test).
Time and events, which deals with the person's experience with time, with disorders involving time speeding up or slowing down, time breaking up or becoming fragmented, and constant anticipation of something major about to happen.
Other persons, which deals with the person's experience of other people, with disorders including disruptions of the sense of ego boundaries with other people, referential ideation based on actions or words by other people, and loss or lack of the ability to naturally understand social situations and social cues leading to attempts to compensate through increased focus or concentration.
Language, which deals with reduced fluency and disruption of prose in one's native language, distortions in the person's expression which causes others to misunderstand the person, problems with concrete and abstract concepts, and distraction by individual words and phrases leading to the person having difficulty following what they are reading or listening to.
Atmosphere, which deals with the person's overall feeling-state of the world, with disorders including derealization (particularly The Truman Show-style derealization), objects no longer having normal meaning, hyper-awareness of things that normally stay in the background of awareness, apophanous mood, and a sense of radical changes in the very structure of the universe itself.
Existential orientation, which deals with radical changes in a person's worldview, dealing with such things as rejecting society's conventions and rules, being extremely open to believing new ideas, and grandiosity which involves the person considering others to be inferior, like insects compared to them.[15]
1.1 Abnormal intensity or persistence of visual perceptions
Visual stimuli appear more or less intense or take longer to leave perception after ending.
1.1.1 Increase in intensity of visual perceptions*
Visual stimuli seem more intense, such as light being brighter or colors stronger.
1.1.2 Decrease in intensity of visual perceptions*
Visual stimuli seem less intense.
1.1.3 Recurrence or prolongation of visual stimuli
Even after visual stimuli are gone, person continues to see them. Also called palinopsia.
1.2 Blindness or partial blindness
Vision is experienced as being blurry or partially or wholly absent.
1.2.1 Blurred vision*
1.2.2 Partial seeing
Person sees only part of an object.
1.2.3 Transitory blindness
Visual field is experienced as either partly or entirely absent.
1.3 Disturbances involving verticality (accuracy) of visual perceptions*
Mis-seeing objects or perceiving visual stimuli that is actually absent.
1.3.1 Visual illusions*
Person mis-sees something, mistaking it for something else.
1.3.2 Visual hallucinations*
Person experiences seeing something when nothing is there. Can seem only partially external.
1.3.3 Visual pseudohallucinations*
Like visual hallucinations, but person while experiencing it recognizes its lack of basis in reality.
1.4 Visual fragmentation
Objects or scenes appear broken up.
1.4.1 Object fragmentation
Cannot perceive objects as a whole.
1.4.2 Break-up of a scene
The world becomes fragmented, with different things appearing disconnected or unrelated to one another.
1.4.3 Captivation of attention by isolated details
Person attracted to certain details as if spellbound.
1.5 Disorganization or disturbed object stability
Visual perception of things becomes fluid and unstable.
1.5.1 Disorganized object contours
Object contours are distorted.
1.5.2 Loss of perceptual stability (fluidity or contamination)
Things seem to change their form or nature before the person's very eyes. Multiple forms of a single object may be perceived simultaneously in the same place, like a "photographic double exposure". (See also the fluidity and contamination ratings on the Rorschach test.)
1.6 Changes in quality, size, or shape of visual perceptions
1.6.1 Changes in color of visual perceptions
Things seem to be a different color from what they normally are.
1.6.2 Micropsia/macropsia
Things seem bigger or smaller than they actually are.
1.6.3 Dysmegalopsia
Things seem bigger on one side and smaller on the other than they actually are.
1.6.4 Metamorphopsia
Objects have a different but stable form than how they actually are.
1.6.5 Other distortions
1.7 Disturbances of perceptual distance or object juxtaposition
Distances and/or relative positioning of objects to each other is distorted.
1.7.1 Objects seem closer or farther away*
Objects are closer or farther than they appear.
1.7.2 Disturbance of relative spatial relationship (juxtaposition) of objects
The relative positioning of objects is distorted, including in the perception of 2 objects one of which is closer, with the closer one appearing farther away and the farther away one appearing closer. May have difficulty determining what is in the background or foreground.
1.7.3 General disturbances in estimation of distance
Person struggles to estimate how far away they are from something.
1.8 Distorted experiences of space
Space itself seems distorted.
1.8.1 Diminished perspectival orientation
Experiences space as isotropic, sees the world as if standing from nowhere in particular or everywhere at once.
1.8.2 Loss of topographical orientation
Feels disoriented in familiar places.
1.8.3 Loss of spatial integrity or structure
Feels as if space is inconsistent, as if pouring a jug of water down on the floor below results in the water falling onto the floor above or as if a path leads somewhere that should be geometrically impossible.
1.8.4 Loss of dimensionality
Perceives the world in only 2 dimensions.
1.8.5 Experience of infinite space
Person is overwhelmed by the magnitude of space in their location.
1.8.6 Figure/ground reversal
Person sees the space between objects rather than the objects themselves.
1.8.7 Affective experience of space*
Space feels threatening or strange, takes on a negative feel.
1.9 Abnormal intensity or persistence of auditory perceptions
Sounds seem more or less intense or last longer than they should.
1.9.1 Increases in intensity of auditory perceptions*
Sounds seem louder or more intense.
1.9.2 Decreases in intensity of auditory perceptions*
Sounds seem quieter or less intense.
1.9.3 Heightened awareness of background auditory sensations
Overly aware of sounds that should remain in the background, that are less relevant than other more important sounds.
1.9.4 Recurrence or prolongation of auditory stimuli
Sounds last longer than they should or recur.
1.10 Disturbances involving veridicality (accuracy) of auditory perceptions*
Mis-hearing sounds or hearing sounds that aren't there.
1.10.1 Auditory illusions*
Mis-hears sounds as something else.
1.10.2 Auditory hallucinations*
Hears sounds that aren't there, in a way that seems at least somewhat external to the person.
1.10.3 Auditory pseudohallucinations*
Like auditory hallucinations, but person is aware during the experience that they are false.
1.11 Other changes in quality of auditory perceptions
Experiences distortions in pitch, timbre, or other qualities of some or all sounds.
1.12 Problems localizing sounds
Has trouble pinpointing where sounds are coming from.
1.13 Disturbances of other senses*
Other senses, such as smell, taste, or touch, experience distortions.
1.13.1 Tactile disturbance*
Distortions in the sense of touch.
1.13.2 Gustatory disturbance*
Distortions in the sense of taste.
1.13.3 Olfactory disturbance*
Distortions in the sense of smell.
1.14 Synesthesia or abnormal concommitant perception*
Stimulus in one sense brings in involvement of another sense.
1.15 Splitting-off or isolation of sensory perceptions
Stimulus is perceived as having nothing to do with what is producing the stimulus, like another person's voice seems to have nothing to do with the person who is speaking.
1.16 Disturbances in recognizing or identifying an object of perception
Fails to recognize what they are seeing or hearing, even when it is familiar to them.
1.17 Loss of boundaries with, or demarcation from, the physical world
Person experiences difficulty determining where their body ends and the rest of the world begins.
Domain 2: Time and events
Symptom
Description
2.1 Time or movements appear to change speed
This does not only occur when a person is bored, excited, or is engaged in activity.
2.1.1 Time or movements seem speeded up*
2.1.2 Time or movements seem slowed down*
2.1.3 Time or movements seem (somehow) both speeded up and slowed down
2.2 Discrepancy between internal and external time*
Experiences discrepancy between the time that passes for their own actions versus the time for the rest of the world.
2.2.1 Internal time seems slower than external time*
Feels as if they are moving or thinking very slowly relative to the rest of the world.
2.2.2 Internal time seems faster than external time*
Feels as if they are moving or thinking much faster than others and the rest of the world.
2.3 Disruption of dynamic organization of time
Seems like time no longer flows like it should. Here, there is a disruption of the unity of the present moment with the retention (immediate previous moment, "primary remembrance") and the protention (immediate next moment, "anticipation"), as described by philosopher Edmund Husserl.
2.3.1 Time feels as though completely stopped, static, infinite, disappeared
Feels as if time has stopped or ceased to exist.
2.3.2 Time as disjointed or fragmented
Each moment feels disconnected from the last and the next, as if time itself has become staccato, just a sequence of photographs, each having nothing to do with the next or last one.
2.3.3 Disorientation in time
Person becomes confused about the passage of time, with difficulty understanding how time flows and when to engage in events, and even what time of day it is.
2.3.4 Feeling limited to or isolated in the present moment
Person feels as if they newly come into being as a wholly different person with each passing moment of time.
2.3.5 Various bizarre experiences of time
Feels as if time is going backward, as if they are stuck in a Groundhog Day loop, as if they control time, as if they are present in multiple periods of time at once, or other bizarre experiences.
2.4 Disturbed anticipation
Disturbance of the expectation of the immediate next moment in time.
2.4.1 Perpetual anticipation
Constantly feels as if something very big is imminent, right about to happen. Called also ante festum experience or trema ("stage fright").
2.4.2 Constant surprise due to inability to anticipate future events
Is constantly surprised by mundane events that would normally be expected immediately beforehand, due to the inability to anticipate.
2.4.3 Feeling that "anything could happen"
Feeling that literally anything, from the probable through the highly unlikely to the impossible, could happen, while not caring what that is.
2.4.4 Protention (future directedness) collapses
Feels as if they cannot move into the imminent next moments in a smooth, flowing way.
2.5 Disturbed awareness of the expected future*
The conception of the future beyond the imminent is distorted or feared in some way.
2.5.1 Future seems nonexistent*
2.5.2 Future seems unimportant or irrelevant*
2.5.3 Future seems threatening*
2.5.4 Premonitions*
2.6 Disturbed experiences of memories or of the past
2.6.1 Past seems cut-off*
2.6.2 Past seems vague or obscure*
2.6.3 Past disappears or seems non-existent*
2.6.4 Past seems accelerated*
Feels as if the memories are all condensed into a single moment.
2.6.5 Past seems slower*
Feels as if memories are all drawn out and elongated in time.
2.6.6 Intrusiveness of the past*
The past seems to limit the person, what they can do.
2.6.7 Erosion of distinction between past and present*
Confused about whether the person is remembering something or if they're actually doing something right now.
2.6.8 Past seems disjointed
What happened in the past seems all out of order, all disconnected from each other, or otherwise disjointed.
Domain 3: Other persons
Symptom
Description
3.1 Lack of social understanding or interpersonal attunement (hypoattunement)
Person feels they cannot smoothly engage with other people at all; may feel like they must study and follow explicit rules to interact successfully with other people.
3.1.1 Loss of social common sense
Feels they cannot naturally grasp what other people do or how the conversation has gone.
3.1.2 Bodily/proprioceptive loss of attunement
Feels they are outward and cannot time their mannerisms and other actions properly (e.g. may not know when to begin speaking after another person has finished, or when to greet a person as they walk past them).
3.1.3 Specific difficulty understanding non-verbal communication
Has difficulty reading body language, tone of voice, and other forms of non-verbal communication.
3.2 Sense of remoteness from others*
Feels cut off from other people.
3.3 Alienated strategies for understanding others
Feels they have to engage in intellectual-style analysis of social situations to understand what they mean and what to do.
3.3.1 Alienated scrutinizing of others' behavior
Aware they tend to analyze social situations to know what they mean, like a zoologist out in the field doing in situ study of animals.
3.3.2 Algorithmic approach to social understanding/interaction
Person attempts to create algorithms, a set of formal rules, to use to guide them in social situations.
3.4 Sense of inferiority, criticism, or mistrust in relation to others*
Tends to feel threatened and criticized in social situations, making it hard to interact comfortably.
3.4.1 Feelings of self-consciousness, self-criticism*
Tends to be overly aware of flaws in their appearance, interaction, etc.
3.4.2 Feelings of social paranoia or social anxiety*
Feels people they're interacting with or are around them are constantly focusing on and judging them.
3.4.3 Pervasive mistrust of others*
Tends to feel other people are out to "get" them.
3.5 Torment or distress due to generalized social insecurity
Mere presence of others feels extremely burdensome and unbearable, as if by their very presence they endanger the person's cold self.
3.6 Interference by voices*
Feels like voices prevent them from interacting normally with people.
3.7 Disturbance of self-other demarcation
Feels like they have a hard time telling what thoughts, ideas, actions, sayings are in them, and what are in other people.
Feels like their innermost thoughts and feelings are open to being read by others.
3.7.4 Experiences of being controlled
Feels like they're being mind-controlled.
3.7.5 Merging or fluid psychological boundaries
They feel mixed up or confuse their thoughts and feelings with those of other people. May feel like there is no clear boundary between themselves and other people.
3.7.6 Universal merging with others*
Feels like there are no individuals, but everyone is part of the same hive mind or other collective consciousness.
3.7.7 Uncertain personal identity/attitudes*
Feels confused about their identity when around others.
3.7.8 Uncertain physical boundaries
Has difficulty telling where their body ends and other people's bodies begin.
3.7.9 Experience of being imitated
Feels like other people are imitating them deliberately to mess with them or make fun of them, in a way that seems strange to them.
3.8 Difficulties with the gaze
Has trouble with eye contact
3.8.1 Intrusiveness of the gaze of the other
Feels like other people's gazes are very intrusive and make them uncomfortable, often leading to avoidance of eye contact.
3.8.2 Feeling of exposure through one's own eyes
Feels like eye contact exposes their innermost thoughts and feelings to the other person.
3.8.3 Intrusiveness of one's own gaze
Feels like their own gaze is intrusive and unbearable for others.
3.8.4 Dehumanization of the eyes of others
When making eye contact, the other person does not seem to be human or alive, with their eyes and body parts being seen as like inanimate objects.
3.8.5 Eyes as cosmic portals
Feels like the eyes of others (or one's own in the mirror) are windows into another world or dimension.
3.8.6 Unspecific uneasigness with gaze
Feels uneasy with eye contact without specifying the reason.
Feels as if other people are dead (even though they're alive, up and moving around).
3.9.2 People seem unreal/false/illusory
Other people seem like they don't really exist or are fraudulent copies of themselves, without objective reality.
3.9.3 People seem mechanical
Other people seem like they are mere robots without a soul.
3.10 Persons dominated by a single characteristic
Focuses on a single characteristic of other people, and feels as if it defines the other person's entire being, like the other person is nothing more than that characteristic.
3.11 Heightened intensity, aliveness, or reality of others*
People seem more alive and energetic than normal, which feels fishy.
3.12 Changes in quality or tone of others' appearance
Other people look or seem strangely different from how they normally are.
3.12.1 People seem familiar in a strange way
Of people they've never met before, it strangely feels like they know the other person from somewhere. Like deja vu, but with people.
3.12.2 People seem unfamiliar in a strange way
Of people they know well, it strangely feels like they don't know the other person at all. Like Jamais vu, but with people.
3.12.3 People seem disgusied*
Feels like other people aren't actually those other people, but are people disguised as those other people.
3.12.4 People seem threatening in a strange way*
There is something about other people that makes it seem like they are a threat.
3.12.5 General/unspecified changes in the physical appearance of others
Something about how the other person looks, like maybe their eyes or face, seems strangely different from before.
3.13 People seem as if communicating something special or unusual (beyond the obvious)
Other people seem to be dropping hints intended for the person, with the intent of the other people's speech being very different from what is said.
3.13.1 Paranoid significance*
The hint seems to express dislike or threats toward the person.
3.13.2 Grandiose significance*
The hint seems to signify the person's superiority or special powers.
3.13.3 Metaphysical significance
The hint seems to signify impending Doomsday or perhaps a cataclysm that has fundamentally altered the universe.
3.13.4 Unknown/unsalatable significance
The person cannot express the meaning of the hint.
3.14 Anomalous behavior/attitudinal responses to others
Person is aware they are acting strangely differently toward other people, often due to paranoia or not understanding social situations like they used to.
3.14.1 Active withdrawal*
Person tends to want to be alone and shut others out.
3.14.2 Oppositional/rebellious behavior*
Person tends to want to act counter to other people.
3.14.3 Social disinhibition*
Person aware they disregard social norms when they interact.
3.14.4 Compulsive interpersonal harmony*
The person feels very eager to please and will do anything to avoid conflict with others.
3.14.5 Extreme compliance
Automatic obedience or imitation of others, echopraxia.
3.14.6 Compulsive clownery/entertainment of others
Feels like they must always crack jokes or clown around, in a way that turns out wooden or stilted to other people.
Domain 4: Language
Symptom
Description
4.1 Basic disruptions of standard verbal comprehension
Difficulty comprehending speech or writings
4.1.1 Meaning/sound dissociation
Difficulty putting the representations of words with their meanings when heard or read
4.1.2 Distraction via semantic possibilities
Gets caught up on all the different senses of a word or a statement that was just heard or read
4.1.3 Distraction by individual words
Gets focused on individual words instead of the message as a whole
4.1.4 Unspecified difficulty understanding
It's difficult to understand what they're hearing or reading
4.2 Difficulty understanding emotional/expressive aspects of speech*
Has a hard time with understanding the intonations in what people say
4.3 Specific changes in standard feel or meaning of words
Becomes focused on words because they feel different than they did before
4.3.1 Focus on sound or appearance of words/phrases*
Very aware of how words sound or appear
4.3.2 Unconventional semantic determination via signifier or fragments of words
Determines words' meanings by how they or parts of them look, rather than by the conventional meaning
4.3.3 Words seem arbitrary/absurd
Is often so distracted by how arbitrary words seem that they do not attend to conversations
4.3.4 Words or language seems alive
Words take on a life of their own or feel like physical objects
4.3.5 Egocentric linguistic reference
Self-referencing ideas coming from the specific words or grammar that a person uses, but NOT the content of what they're saying.
4.4 Unconventional word choice, grammar, tone, or cryptic discourse
Says things in an unusual manner that often confuses people, which may be at least somewhat willful.
Speaks in a cryptic manner or using sentences structures that violate the grammar of the language they're speaking (even though they are a native speaker, for example), which may be experienced as intentional.
4.4.2 Stock words
Tends to overuse a certain few words or phrases to the point where they acquire many meanings beyond the conventional, causing their speech to feel stilted.
4.4.3 Made-up words (neologisms) or unconventional usage
Aware of using made-up words or using words in ways that differ greatly from their meanings.
4.4.4 Mannerisms and stilted speech
Tends to use very formal registers to say things in situations that would normally call for more casual speech.
4.5 Disturbed fluency
Has a hard time expressing self using language
4.5.1 Unavailability of words
Cannot find the right words
4.5.2 Unfocused or disorganized thoughts preclude verbal expression
Aware they have difficulty speaking because they cannot get their thoughts "straight", that is, their thinking has become so digressive or otherwise difficult to understand that they cannot express themselves
4.5.3 General discordance between the intended expression and the expressed
Aware of inability to express themselves in a way that accurately expresses what they meant to say; little things in the expression keep being off to the point the listener or reader may be left with a different impression.
4.6 Disturbed relevance
Aware of having a hard time remaining on a single line of thought while talking or writing
4.6.1 Derailment*
Aware that they have a tendency to lose track of what they're saying or writing.
4.6.2 Tangential responding
Aware that they make off-topic answers to questions
4.7 Disturbance of linguistic engagement or purposefulness
Aware they speak in such a strange way that they are not engaging
The person feels like they are the only mind in the universe and that they are the ones who build up the universe and bring things and people into being.
5.13.2 Double bookkeeping
Aware of two different realities, one real and physical, the other imaginary and delusional.
5.13.3 Influencing physical reality
Feels like their thoughts control the world
5.13.4 Pseudomovements of objects/persons
When the person is moving, it feels like things or people are moving in conjunction with them.
5.14 Revelatory or pseudorelevatory (apophanous) mood
There is something different, special, or unusual about the world, but the person cannot grasp it, filling them with wonder.
5.14.1 Uncanny particularity
Something seems peculiar about various mundane happenings in the world, like they signify something bigger happening behind the scenes.
5.14.2 Self-referentiality
Sees mundane things as referring back to themselves in one of various ways, listed below.
5.14.2.a Paranoid significance*
Suggests someone is trying to harm them
5.14.2.b Grandiose significance
Suggests they are superior or special in some way
5.14.2.c Metaphysical significance
Suggests the entire universe has radically changed, with the implication that it is the person who is response, or the message is directed specifically toward them.
5.14.2.d Unknown/unsalatable significance
The nature of the significance is unknown.
5.14.3 Unspecifiable strangeness
Something has changed, the person can sense it, but they don't know exactly what.
5.15 Quasi-mystical experiences
Amazed at the very existence of the world
5.15.1 Mystic union with the world*
Feels especially connected and united with the world, but not in a way that suggests their ego boundaries have been compromised.
Feels euphoric, but in a way that is very disconnected, different than the euphoria in a manic state which tends to involve increased energy and actions toward goals.
5.17.6 Despair, demoralization, hopelessness*
5.17.7 Abnormalities of mood constancy*
5.17.7.a Mood or emotion is abnormally present*
Feels like the mood lasts beyond the events or thoughts that triggered it.
5.17.7.b Mood or emotion is abnormally labile*
Mood keeps changing
5.17.8 Incongruity of mood or emotion
5.17.8.a Mood or emotion inappropriate to the current situation
Has moods or emotional reactions one would expect to what's going on
5.17.8.b Moods or emotions are mutually contradictory
Very high level of ambivalence about how they feel about things
Domain 6: Existential orientation
Symptom
Description
6.1 Rejection of society or convention
The person generally chooses to live according to their rules in disregard of societal norms.
6.1.1 Disinclination for human society
Person rejects society and would prefer to live as a misfit.
6.1.2 Antagonomia
Tends to act in ways that directly oppose societal values.
6.1.3 Idionomia
Person feels radically unique.
6.2 Extreme indifference or openness
Person is very open to all possibilities in a way suggesting they are detached from the normal concerns of life.
6.2.1 Attitude of indifference, insouciance, lack of concern
Expresses "callous indifference" and that nothing really matters, in a way suggesting cold detachment, different from the way indifference is typically expressed in mood disorders where there is a strong emotional component.
6.2.2 Conceptual freedom/anything goes
Feels like anything could happen: as far as they're concerned, for example, apples could just as easily start falling up from trees rather than down.
6.3 Pervasive disbelief, skepticism, or curiosity re the obvious, taken-for-granted
Constant tendency to question everything that society takes for granted.
6.4 Absolute certitude
The person is absolutely sure about their unusual interpretation of the world, and does not believe that it will ever be refuted.
6.5 Feeling of being special or superior
Person feels superior or like they have a special role to play in the universe.
6.5.1 Feeling of extraordinary insight*
Person feels as if they and they alone understand the mysteries of the world.
Person feels as if they are much much more highly advanced and evolved than all other people, whom they view as vastly inferior.
6.6 Impossible responsibility or guilt*
Person feels guilty over things they could not have done.
6.7 Sense of loss of freedom or individuality
Feels as if they are controlled by outside forces.
6.8 Adherence to abstract, intellectualistic, and/or autonomous rules
Person follows self-imposed "rational" rules that are quite idiosyncratic.
6.9 Existential or intellectual change*
Person suddenly is absorbed by things like religion or philosophy.
6.10 Feeling of centrality
Person feels as if the universe revolves around them.
6.11 Decentering of the self relative to universe
Feels as if they are not really real, like they truly exist apart from the universe.
*Indicates experience that can also occur in other primary psychotic or mood disorders outside the schizophrenia spectrum, such as delusional disorder, major depressive disorder, or bipolar disorder.
The presence of self-disorders may have predictive power for whether those with an at risk mental state will develop psychosis;[16][17] the risk of suicidal ideation and suicide by people with schizophrenia, though depression would also be an important factor;[18] predicting initial social dysfunction in people with either schizophrenic or bipolar psychosis;[19] and whether a person will move to a schizophrenia spectrum diagnosis later.[20]
Considering the presence of self-disorders is useful when attempting to differentially diagnose disorders that can be confused with schizophrenia spectrum disorders. Autism spectrum disorder and schizotypal personality disorder can appear outwardly similar but have different etiologies and require different treatment approaches.[3][21] The presence of self-disorders is evidence for a diagnosis of schizotypal personality disorder over autism spectrum disorder.[21][22] Likewise, in the case of first instance psychosis, self-disorders are indicative of a diagnosis of schizophrenia in favor of other psychotic disorders.[23]
The presence of self-disorders may cause reduced person insight into their illness through the alteration of the basic structures of consciousness.[2][7]
Self-disorders are difficult for the people experiencing them to articulate spontaneously;[6][24] and are not well-known, by either the general public or professionals in the field. Because of this, people will often make vague, clichéd complaints that mimic the symptoms of other mental disorders, symptoms such as "fatigue" or "concentration difficulties". Were a knowledgeable clinician to probe deeper, however, the underlying self-disorders may be assessed and help clarify the nature of the person's illness. In their review, Parnas, et al. (2014) say, "The psychiatrist's acquaintance with the phenomenon of 'non-specific specificity' is, in our view, extremely important in the context of early diagnostic assessment, especially of people presenting with a vague, unelaborated picture of maladjustment, underperformance, chronic malaise and dysphoria, negative symptoms, or hypochondriac preoccupations." People with schizophrenia often describe their self-disorders as causing more suffering for them than psychosis.[2]
Self-disorders underlie most of the first-rank symptoms, those often termed passivity phenomena. There is a current proposal to list self-disorder as one of the symptoms of schizophrenia in the upcoming ICD-11.[25]
The first systematic review of empirical studies on self-disorders based on the EASE scale was published in 2021. It found consistent support for the concept as a characteristic component of schizophrenia spectrum disorders and not other mental disorders.[1] Another systematic review and meta-analysis from 2022 covering an aggregated sample of 810 patients found good evidence to support the existence of self-disorders as core clinical feature in schizophrenia spectrum disorders.[26] The concept and its link to schizophrenia was likewise supported by a 2021 meta-analysis.[27]
In a 2014 review, Postmes, et al., suggested that self-disorders and psychosis may arise from attempts to compensate for perceptual incoherence and proposed a hypothesis for how the interaction among these phenomena and the person's attempts to resolve the incoherence give rise to schizophrenia. The problems with the integration of sensory information create problems for the person in keeping a grip on the world, and since the self-world interaction is fundamentally linked to the basic sense of self, the latter is also disrupted as a result.[28] Sass and Borda have studied the correlates of the dimensions of self-disorders, namely disturbed grip (perplexity, difficulty "getting" stuff most people can get), hyperreflexivity (where thoughts, feelings, sensations, and objects pop up uncontrollably in the field of awareness, as well dysfunctional reflecting on matters and the self), and diminished self-affection (where the person has difficulty being "affected" by aspects of the self, experiencing those aspects as if they existed in an outer space), and have proposed how both primary and secondary factors may arise from dysfunctions in perceptual organization and multisensory integration.[29][30]
In a 2013 review, Mishara, et al., criticized the concept of the minimal self as an explanation for self-disorder, saying that it is unfalsifiable, and that self-disorder arises primarily from difficulty integrating different aspects of the self as well as having difficulty distinguishing self and other, as proposed by Lysaker and Lysaker: Ichstörung or ego disorder, as they say, in schizophrenia arises from disturbed relationships not from the "solipsistic" concept of the self as proposed by Sass, Parnas, and others.[31] In his review, Sass agrees that the focus of research into self-disorder has focused too much on the self, and mentions attempts to look at disturbances in the person's relationship with other people and the world, with work being done to create an Examination of Anomalous World Experience, which will look at the person's anomalous experiences regarding time, space, persons, language, and atmosphere; he suggests there are problems with both the self and the world in people with self-disorder, and that it may be better conceptualized as a "presence-disturbance".[10] Parnas acknowledges the Lysaker model, but says that it is not incompatible with the concept of the minimal self, as they deal with different levels of self-hood.[2]
The concept of a basic self-disturbance in schizophrenia appears in all the foundational texts on the disease.[2][32] The basic symptoms of schizophrenia include descriptions of self-disorders.[6] Likewise, Kurt Schneider's first-rank symptoms, especially his concept of ego disturbances [de] as well as the so-called passivity phenomena may be considered as examples of self-disorders.[33][34] Similar concepts were also discussed by Karl Jaspers.[34] The concept of "ontological insecurity", which resembles self-disorder, was proposed by R. D. Laing in 1960.[35]
The publication of the DSM-III (1980) lead to an increased emphasis on concrete signs and symptoms of mental disorders over the subjective experiences underlying those symptoms; in other words, it privileged a behaviorist approach to diagnosis. Because the concept of self-disorders had been difficult to operationalize, it began to be criticized as overly vague and too subjective; indeed, little systematic or empirical research was done on the concept in the 20th century. It therefore began to fall out of clinical use and soon disappeared entirely from training programs in the United States.[2][32][36]
A notable exception to this trend was the Bonn Scale for the Assessment of Basic Symptoms (BSABS), created in the 1980s to assess sub-clinical affective, cognitive and perceptual disturbances, as well as basic self-disturbance.[36] In many studies, basic symptoms as measured by the BSABS were found to aggregate in people with schizophrenic and schizotypal disorders.[24]
In early 2000s, a group of researchers including Danish psychiatrist Josef Parnas sought to operationalize and revive the idea of schizophrenia as a disorder of the minimal self.[34] This work resulted in the creation of the EASE, which was published in 2005.[6][2] The scale was based on phenomenological interviews with first-admission people with schizophrenia spectrum disorders, to enable empirical research of self-disorders.[6][2] It was also partially based on the BSABS, but more focused on items relating specifically to disturbed self-experience.[34] The creation of the EASE resulted in an uptick in research into the topic, and the first systematic review of the concept was published in The Lancet Psychiatry in 2021, finding good empirical support for self-disorders as a defining characteristic of schizophrenia spectrum disorders.[1]
^Elisabeth Haug, Ingrid Melle, Ole A. Andreassen, Andrea Raballo, Unni Bratlien, Merete Oie, Lars Lien & Paul Moller (July 2012). "The association between anomalous self-experience and suicidality in first-episode schizophrenia seems mediated by depression". Comprehensive Psychiatry. 53 (5): 456–460. doi:10.1016/j.comppsych.2011.07.005. PMID21871617.{{cite journal}}: CS1 maint: multiple names: authors list (link)
^Elisabeth Haug, Merete Oie, Ole A. Andreassen, Unni Bratlien, Andrea Raballo, Barnaby Nelson, Paul Moller & Ingrid Melle (April 2014). "Anomalous self-experiences contribute independently to social dysfunction in the early phases of schizophrenia and psychotic bipolar disorder". Comprehensive Psychiatry. 55 (3): 475–482. doi:10.1016/j.comppsych.2013.11.010. PMID24378241.{{cite journal}}: CS1 maint: multiple names: authors list (link)
^Heinz, A.; Voss, M.; Lawrie, S. M.; Mishara, A.; Bauer, M.; Gallinat, J.; Juckel, G.; Lang, U.; Rapp, M. (2016-07-15). "Shall we really say goodbye to first rank symptoms?". European Psychiatry. 37: 8–13. doi:10.1016/j.eurpsy.2016.04.010. ISSN1778-3585. PMID27429167. S2CID13761854.
