Editorial

Varieties of self-disturbance: a prism throughwhich to view mental disorder

There seems to be growing talk of ‘the self’ in psy-chiatry and related disciplines (perhaps encouragedby the great success of Apple’s ‘i’ products? Notsure.). There are of course many different meaningsascribed to the term ‘self’, with the philosopherStrawson1 counting 21 notions of ‘self’ in contem-porary literature, and also a variety of ways in whichthe ‘self’ might be disturbed (see Lysaker andLysaker2 for a comparison of six perspectives onalterations of self-experience in schizophreniaalone). Varieties of self-disturbance is a loose themerunning through some of the papers published inthis issue of Early Intervention in Psychiatry.

Several levels of ‘the self’ can be delineated thatassist with organizing the multitude of approachesto the construct:3,4

1 The ‘basic’ self, also referred to as the ‘minimal’ or‘core’ self, or as ‘ipseity’ (ipse being Latin for ‘self’or ‘itself’). The ‘basic’ self is a pre-reflective, tacitlevel of selfhood. It derives from the given factthat all experience has a first-person quality, thatthere is an implicit ‘ownership’ of experience orawareness that this is my experience. The term‘basic’ reflects the notion that this level ofselfhood is the ground on which other levels ofselfhood are built.3,4

2 The ‘reflective’ self. Reflective self-awareness is arelatively more explicit awareness of the self as aninvariant and persisting subject of experience andaction – ‘my sense of myself as the same personthrough time’, for example.

3 The ‘narrative’ or social self. This refers to charac-teristics such as personality, habits, style, per-sonal history, and so on (e.g. ‘I am a flexible sort ofperson, often accommodating to other people’sneeds. This may be related to being a middlechild, etc.’). This is the level of selfhood addressedin the work of seminal figures such as Mead andVygotsky.

Ackroyd5 in this issue of the journal reviews themodel of basic self-disturbance (level 1 above) as acentral or ‘core’ feature of schizophrenia and its rela-tionship with the early intervention paradigm. Asdescribed by Ackroyd,5 disturbance of the basic selfcan be expressed as an unstable ‘first-person’ per-spective associated with forms of depersonalization

and dissociation, disturbance of the normallyimplicit sense of agency and ‘ownership’ of experi-ence, various anomalous subjective cognitive andphysical experiences, a diminished sense of coher-ence and consistency in fundamental features ofself (e.g. sense of anonymity, identity confusion,etc.), disturbed self-other/self–world boundaries,and disturbance of implicit common social under-standing (‘common sense’; see Parnas et al.,6 forfurther description). This formulation of the centraldisturbance in schizophrenia provides a parsimoni-ous way of understanding not only the evolution ofpsychotic symptoms and the often shifting expres-sion of its single features in individual patients (i.e.why one symptom might recede and anotherbecome more prominent),7 but also the profoundtransformations of subjectivity that often accom-pany the condition. First-person accounts ofschizophrenia are replete with descriptions of thisform of self-disturbance as a central and particu-larly distressing feature of the disorder (e.g. Saks8),as Ackroyd draws our attention to. It should benoted that this form of self-disturbance is quite dis-tinct from the disturbing impact psychotic illnesscan have on an individual’s sense of self,9 suchas perceived devaluing and rejection by others, aconstruct found to be important in Norman andcolleagues’ study of subjective recovery from psy-chosis,10 also in this issue of the journal. Basic self-disturbance is more appropriately viewed as avulnerability factor than a reaction to psychosis.

Ackroyd’s historical perspective on the constructof schizophrenia is timely given the recent release ofthe Diagnostic and Statistical Manual of Mental Dis-orders, Fifth Edition. He reminds us of the centralrole disturbances of the self played in early descrip-tions of schizophrenia, and how the emphasisplaced on improving the reliability of the diagnosissubstantially diluted these aspects of how the disor-der is conceptualized (also see Andreasen11 andParnas7 on this topic). Ackroyd5 concludes that thebasic self-disturbance model captures importantchanges to subjective experience that occur in theearly phase of psychosis and that the model couldbe usefully integrated into the early interventionapproach. To some extent, such integration mightact as a corrective to ‘the reduction of diagnostic

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concepts to tick-box lists of objective symptoms’ (p.238). Indeed, the growth of interest in the basic self-disturbance model reflects a general resuscitation ofinterest in subjectivity and phenomenology.

If basic self-disturbance is indeed a centralfeature of schizophrenia (although the empiricaldata to date are strong, further studies are requiredto buttress this view), then it will of coursebe invaluable to clinical work: it may help guideearly identification, diagnostic discrimination,inform the therapist’s ability to properly empathizewith the subjective disturbances experienced bypatients, guide clinical formulations and ‘psychoe-ducation’ work, and inform treatment approaches.Incorporating basic self-disturbance into the thera-peutic frame should not be viewed as some form ofluxury that can be indulged in once more criticalissues have been addressed. Recent studies haveshown that disturbances of the basic self are one ofthe main drivers of suicidality (ideation and behav-iour) in those diagnosed with schizophrenia, moreso than positive symptoms (e.g. Skodlar andParnas12), and possibly also lack of insight intoillness, contributing to non-compliance with treat-ment.13 Although it may not always be the most

obvious form of loss, as Ackroyd’s quote ofKierkegaard illustrates, it would be a serious clinicaldisservice not to notice the quiet dissolution ofbasic selfhood.

Although the integration of the basic self-disturbance concept into the early interventionparadigm would no doubt be useful (and may tosome extent address the issue of falling transitionrates in ‘ultra high-risk’ (UHR) samples14), we shouldnot lose sight of the fact that the two models aredirected at somewhat different targets. The focus ofthe former is schizophrenia and the schizophreniaspectrum, while the latter takes the broader cat-egory of psychosis and risk thereof as its target, withintensity/frequency of positive psychotic symptomsas the guiding barometer. In this sense, the conceptsare on somewhat different axes, with the basic self-disturbance concept cutting across the divide in theearly psychosis field between UHR and first-episodepsychosis (FEP) samples. Figure 1 is a heuristicmodel that conveys this idea. Although some casesmay display prominent basic self-disturbance fea-tures, they may not necessarily be identified as FEPin early intervention clinical/research contexts (e.g.schizotypal/schizoid personality disorders) and,

FIGURE 1. A heuristic model of the relationship between basic self-disturbance and the early intervention in psychosis approach. FEP,first-episode psychosis; NOS, not otherwise specified; PD, personality disorder; UHR, ultra high risk.

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conversely, some cases may sit squarely in the FEPcamp but not be high on the basic self-disturbanceaxis (e.g. mood disorder with psychotic features).There is accumulating evidence that basic self-disturbance in those with threshold psychotic dis-order is particularly prominent in schizophreniapatients compared with other psychotic disorders(e.g. Parnas et al.15). This is not to say that themodels are not complementary, only that theyshould not be conflated.

Nelson and colleagues16 in this issue of the journalreport findings that a measure of basic self-disturbance (the Examination of Anomalous SelfExperience, EASE6) was not associated with ameasure of borderline personality pathology in aUHR sample. This is broadly consistent with theview espoused by some researchers (and relatedempirical data, e.g. Handest and Parnas17) thatborderline personality disorder is marked by a dif-ferent type of self-disturbance than that which iscaptured in the basic self-disturbance model.4

Specifically, using the levels of selfhood outlinedearlier, borderline personality pathology mayconsist mainly of disturbance of the narrative orsocial self (aspects of identity rather than more fun-damental features of self-experience). This is a pilotstudy of this issue, which should be addressed moresystematically in future research.

The online world presents new possibilities forconstruction and enaction of the self. The narrativeor social self is wildly at play on Facebook, tumblrand blogs. There has been a growing focus on howthe online world might be used for mental healthawareness, promotion, support and intervention.Mittal and colleagues,18 also in this issue, deal withthe other side of the coin: the possibility for addic-tion and ‘reality substitution’ that the online worldholds. Their findings show a longitudinal relation-ship between intensification of psychotic-likeexperiences (PLEs) and persistence of problematicInternet use (Internet addiction and ‘reality substi-tution’) in a general population sample of youngadults. Those whose PLEs improved or remainedconstant over time showed a decline in problematicInternet use. Although the authors appropriatelyrecognize that their study design precludes anycausal relationship to be inferred between the twovariables (PLEs and problematic Internet use), theyspeculate that problematic Internet use may be anenvironmental stressor in the aetiology of psychiat-ric disorder or, alternatively, that it may be a copingmechanism for escaping disturbing PLEs or coun-tering social isolation. It is also possible, in line withthe basic self-disturbance model, that personalitytypes with schizotypal or schizoid traits (who are

more likely to experience PLEs) find socialinteractions/relationships threatening, intrusive orotherwise uncomfortable and that the online settingprovides a more tolerable environment for suchinteractions and relationships (see 19 for furtherdiscussion).

There seems to be a number of issues to betackled in the burgeoning field of self-disturbanceresearch, particularly basic self-disturbanceresearch. What exactly is the relationship betweenthe different levels of selfhood delineated earlier?How might they (obviously and perhaps moresubtly) influence each other? As Nelson and col-leagues (16, this issue) speculate, it would seem likelythat disturbance of the basic self would threaten arobust reflective or narrative self, because both ofthese would seem to rely on some stability in one’simmediate, implicit self-experience (includingcomponents such as cognition, bodily experience,temporal flow, self–other boundaries, etc.). Are dis-turbances of the basic self of a trait or a state nature?How can the basic self-disturbance model be inte-grated with other ‘levels’ of enquiry: What are theneurocognitive correlates? What developmentalfactors contribute to emergence of disturbed basicselfhood? What models of the self (and its pathol-ogies) have currency in cognitive science and phi-losophy? There is a need here for cross-domainand cross-disciplinary work; otherwise, researchersin different domains may find themselves inthe unfortunate position of the blind men whotouch different parts of the elephant and are inevi-tably left with a partial and distorted image of thewhole.

Then of course there are practical issues of imple-mentation and clinical intervention. An instrument(EASE) has been developed for the systematicassessment of basic self-disturbance and has dis-played good interrater reliability.6 However, this hasmainly been established in research settings and thequestion still remains as to whether this can betransferred to clinical settings, especially whenabbreviated versions may be called for in suchsettings. This also raises the issue of fosteringthe clinical knowledge, training and skills to achievethe psychopathological expertise to assess suchchanges in self-experience. There is certainly causefor optimism given the widespread and reliableassessment of basic symptoms, a group of symp-toms that overlap with the basic self-disturbanceconstruct. Finally, what therapeutic interventionscan be implemented to address these various formsof self-disturbance? With regards to basic self-disturbance, perhaps cognitive behaviour therapy(CBT; particularly forms of CBT that emphasize the

B. Nelson

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‘cognitive’ element of reflection and challenging)may inadvertently foster a pathological processthat contributes to basic self-disturbance (hyper-reflexive awareness).20 Strategies that encourage aform of immersion or absorption in present activity,including mindfulness, creative ‘flow’ and psycho-social rehabilitation (strengthening social andvocational roles), may be useful in allowing patientsto evolve a more robust basic self (basic senseof agency and ‘ownership’ of experience).20 Theempathic attunement afforded by the phenomeno-logical approach’s sensitivity to subjective experi-ence may also be particularly powerful in patientswhose disturbance of basic selfhood can oftenleave them feeling profoundly alienated fromothers.12,19 Finally, if we gain a better handle on theneurocognitive and developmental aspects of basicself-disturbance then perhaps these also offertargets for early intervention.

Barnaby NelsonOrygen Youth Health Research Centre, Centre for

Youth Mental Health, The University of Melbourne,Parkville, Victoria, Australia

REFERENCES

1. Strawson G. The self and the SESMET. In: Gallagher S, ShearJ, eds. Models of the Self. Thoverton: Imprint Academic,1999; 483–518.

2. Lysaker PH, Lysaker JT. Schizophrenia and alterations in self-experience: a comparison of 6 perspectives. Schizophr Bull[Comparative Study Review]. 2010; 36: 331–40.

3. Zahavi D. Subjectivity and Selfhood: Investigating the First-Person Perspective. Cambridge, MA: MIT Press, 2005.

4. Parnas J. Self and schizophrenia: a phenomenological per-spective. In: Kircher T, David A, eds. The Self in Neuroscienceand Psychiatry. Cambridge, MA: Cambridge University Press,2003; 127–41.

5. Ackroyd MK. You can’t spell schizophrenia without an ‘I’:how does the early intervention in psychosis approach relate

to the concept of schizophrenia as an ipseity disturbance?Early Interv Psychiatry 2013; 7: 238–46.

6. Parnas J, Møller P, Kircher T et al. EASE: examination ofanomalous self-experience. Psychopathology 2005; 38: 236–58.

7. Parnas J. A disappearing heritage: the clinical core of schizo-phrenia. Schizophr Bull 2011; 37: 1121–30.

8. Saks ER. The Center Cannot Hold: My Journey ThroughMadness. New York: Hyperion, 2007.

9. Davidson L. Living outside Mental Illness: Qualitative Studiesof Recovery in Schizophrenia. New York: New York UniversityPress, 2003.

10. Norman R, Windell D, Lynch J, Manchanda R. Correlates ofsubjective recovery in an early intervention program for psy-choses. Early Interv Psychiatry 2013; 7: 278–84.

11. Andreasen NC. DSM and the death of phenomenology inAmerica: an example of unintended consequences.Schizophr Bull 2007; 33: 108–12.

12. Skodlar B, Parnas J. Self-disorder and subjective dimensionsof suicidality in schizophrenia. Compr Psychiatry 2010; 51:363–6.

13. Henriksen MG, Parnas J. Self-disorders and schizophrenia: aphenomenological reappraisal of poor insight and noncom-pliance. Schizophr Bull 2013 June 24 (in press).

14. Nelson B, Yuen HP, Wood SJ et al. Long-term follow-up of agroup at ultra high risk (‘Prodromal’) for psychosis: the PACE400 study. JAMA Psychiatry 2013; 5: 1–10.

15. Parnas J, Handest P, Saebye D, Jansson L. Anomalies ofsubjective experience in schizophrenia and psychotic bipolarillness. Acta Psychiatr Scand 2003; 108: 126–33.

16. Nelson B, Thompson A, Chanen AM, Amminger GP, Yung AR.Is basic self-disturbance in ultra-high risk for psychosis (‘pro-dromal’) patients associated with borderline personalitypathology? Early Interv Psychiatry 2013; 7: 306–10.

17. Handest P, Parnas J. Clinical characteristics of first-admittedpatients with ICD-10 schizotypal disorder. Br J PsychiatrySuppl 2005; 48: s49–54.

18. Mittal VA, Dean DJ, Pelletier A. Internet addiction, realitysubstitution and longitudinal changes in psychotic-likeexperiences in young adults. Early Interv Psychiatry 2013; 7:261–9.

19. Nelson B, Sass LA, Thompson A et al. Does disturbance of selfunderlie social cognition deficits in schizophrenia and otherpsychotic disorders? Early Interv Psychiatry 2009; 3: 83–93.

20. Nelson B, Sass LA, Skodlar B. The phenomenological modelof psychotic vulnerability and its possible implicationsfor psychological interventions in the ultra-high risk (‘prodro-mal’) population. Psychopathology 2009; 42: 283–92.

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