The paradoxical self: awareness, solipsism and first-rank symptoms in schizophrenia

Schizophrenia as a pathology of self-awareness has attracted much attention from philosophical theorists and empirical scientists alike. I view schizophrenia as a basic self-disturbance leading to a lifeworld of solipsism adopted by the sufferer and explain how this adoption takes place, which then manifests in ways such as first-rank psychotic symptoms. I then discuss the relationships between these symptoms, not as isolated mental events, but as end-products of a loss of agency and ownership, and argue that symptoms like thought insertion and other ego-boundary disorders are by nature a multitude of paradoxes created by a fragmented awareness. I argue that such fragmentation does not always require or lead to a delusional elaboration as the definitive feature of its phenomenology, and present reasons for the role of the first-person pronoun as a mere metaphor used to represent the patient’s bizarre experiences where sensory perception and thinking processes converge. Further, I discuss the initial benefits of adopting a solipsistic stance and how despite being a maladaptive strategy, it nevertheless acts as a protective barrier for the integrity of one’s self. Lastly, I offer some suggestions for clinical practice, emphasizing the importance of understanding the patient’s suffering in any therapeutic alliance

The paradoxical self : Awareness, solipsism and first-rank symptoms in schizophrenia

Schizophrenia as a pathology of self-awareness has attracted much attention from philosophical theorists and empirical scientists alike. I view schizophrenia as a basic self-disturbance leading to a lifeworld of solipsism adopted by the sufferer and explain how this adoption takes place, which then manifests in ways such as first-rank psychotic symptoms. I then discuss the relationships between these symptoms, not as isolated mental events, but as end-products of a loss of agency and ownership, and argue that symptoms like thought insertion and other ego-boundary disorders are by nature a multitude of paradoxes created by a fragmented awareness. I argue that such fragmentation does not always require or lead to a delusional elaboration as the definitive feature of its phenomenology, and present reasons for the role of the first-person pronoun as a mere metaphor used to represent the patient’s bizarre experiences where sensory perception and thinking processes converge. Further, I discuss the initial benefits of adopting a solipsistic stance and how despite being a maladaptive strategy, it nevertheless acts as a protective barrier for the integrity of one’s self. Lastly, I offer some suggestions for clinical practice, emphasizing the importance of understanding the patient’s suffering in any therapeutic alliance

Predictive processing and source monitoring in the psychosis continuum

Schizophrenia is a serious and debilitating mental illness, and sufferers frequently experience a multitude of symptoms. Of particular interest to the current Thesis are psychotic symptoms including delusions, hallucinations and associated self- disturbances such as interference in the agency and ownership of thoughts and actions. Since the disorder was first described over a century ago, research into the pathogenesis of schizophrenia has advanced greatly. However, there are still large gaps in the current knowledge and understanding of the neuropsychological bases of this devastating illness. The current Thesis adopts a cognitive neuropsychiatric approach and applies a continuum model to the construct of psychosis. The aim of the current Thesis was to incorporate theories such as the source monitoring and the predictive processing frameworks across a range of behavioural tasks, in order to investigate some of the neuropsychological deficits in schizotypy and early psychotic symptoms. Healthy individuals with schizotypal traits and patients with early psychosis who did not yet meet a full diagnosis of schizophrenia underwent a battery of behavioural paradigms, with each task aimed at a different aspect of predictive processing and source monitoring. In healthy individuals, nonclinical psychosis-like experiences measured with schizotypy scales were significantly associated with difficulties in the source monitoring of actions, in particular deficits in reality monitoring and internal source monitoring. However, no significant relationships were found for the predictive processing tasks, which focused on the perceptual (force-matching), associative (Kamin blocking) and motivational (reversal learning) domains. In the patients with first episode psychosis, positive psychotic symptoms were not significantly correlated with specific deficits in either category of tasks, although this study was under- powered and strong conclusion could not be drawn. Nevertheless, these findings have provided support for partial dimensionality in psychosis vulnerability and will serve as foundations for future research on a larger scale

Deficits in reality and internal source monitoring of actions are associated with the positive dimension of schizotypy

People with schizophrenia have deficits in retrieving the source of memory information. Research has focused on two types of judgements: reality monitoring (discriminating internally-generated stimuli from external information) and internal source monitoring (distinguishing two different internal sources). The aim of the current study was to assess the relation between schizotypy and both types of source memory in healthy volunteers. One hundred and two participants completed two source memory tasks: one involved the completion of well-known word pairs (e.g. Fish and? ) and the other was an action based task (e.g. nod your head). At test participants needed to indicate whether the act had been performed or imagined by themselves, performed by the experimenter, or was new. The positive dimension of schizotypy was positively correlated with errors in internal source monitoring i.e. confusing participant performed and imagined acts. Furthermore, the same dimension of schizotypy was also positively associated with reality monitoring errors i.e. confusing participant performed/imagined with experimenter performed items. However, these relationships were not found in the word pair task. Our findings suggest that there might be overlap in the processes required to retrieve source information from memory, particularly for actions, and the occurrence of unusual experiences in healthy volunteers

Innovations in the psychopathology of schizophrenia : A primer for busy clinicians

Significant developments in schizophrenia psychopathology are ready to be incorporated into clinical practice. These advances allow a way forward through the well-described challenges experienced with current diagnostic and psychopathological frameworks. This article discusses approaches that will enable clinicians to access a wider and richer spectrum of patient experience; describes process-based models of schizophrenia in the domains of both the brain and the mind; and considers how different levels of analysis might be linked via the predictive processing framework. Multiple levels of analysis provide different targets for varying modalities of treatment - dopamine blockade at the molecular level, psychological therapy at the level of the mind, and social interventions at the personal level. Psychiatry needs to align itself closer to neuroscientific research. It should move from a symptom-based understanding to a model based on process. That is - after having asked about a patient's symptoms and experience clinicians need to introduce steps involving a consideration of what might be the brain and mind processes underlying the experience

Prevalence and assessment of self-disorders in the schizophrenia spectrum : a systematic review and meta-analysis

Self-disorders have been proposed as the "clinical core" of the schizophrenia spectrum. This has been explored in recent studies using self-disorder assessment tools. However, there are few systematic discussions of their quality and utility. Therefore, a literature search was performed on Medline, Embase, PsychINFO, PubMed and the Web of Science. Studies using these assessment tools to explore self-disorders within schizophrenia spectrum disorders (SSDs) were included. A meta-analysis was performed on the outcomes of total self-disorder score and odds ratios of self-disorders, using Comprehensive Meta-Analysis software. Weighted pooled effect sizes in Hedge's g were calculated using a random-effects model. 15 studies were included, giving a sample of 810 participants on the schizophrenia spectrum. Self-disorders showed a greater aggregation within schizophrenia spectrum groups compared to non-schizophrenia spectrum groups, as measured with the Bonn Scale for the Assessment of Basic Symptoms (Hedge's g = 0.774, p < 0.01) and Examination of Anomalous Self-Experiences (Hedge's g = 1.604, p < 0.01). Also, self-disorders had a greater likelihood of occurring within SSDs (odds ratio = 5.435, p < 0.01). These findings help to validate self-disorders as a core clinical feature of the broad schizophrenia spectrum

Co-occurring psychotic and eating disorders in England: findings from the 2014 Adult Psychiatric Morbidity Survey

Background Psychotic disorders and eating disorders are complex mental illnesses associated with increased mortality and functional impairment. This study aimed to investigate the co-occurrence and relationships between eating disorders and psychotic disorders and assess the mediation effect of mood instability. Methods This study used data from the Adult Psychiatric Morbidity Survey (APMS) 2014, a general population-based survey in England. Participants (total N = 7546, female N = 4488, male N = 3058, mean age = 52.3 years) were categorised based on psychotic disorder status into the groups of probable psychosis, diagnosed psychosis, and healthy controls without psychosis. The dependent variable of this study was the presence or absence of an eating disorder, with mood instability as the mediator. Logistic regression and mediation analyses were conducted to assess the relationships between these variables. Results Both probable and diagnosed psychoses were significantly related to the presence of an eating disorder, and mood instability was found to be a mediating variable with moderate effect. Conclusion The present study demonstrates a significant relationship between eating disorders and psychotic disorders in the English general population, indicating higher levels of co-occurrence between these two groups of disorders than when compared with healthy controls. The findings also suggest the relationship between eating and psychotic disorders is mediated, to an extent, by the presence of mood instability traits. Future research could extend the present study’s findings through assessing whether specific eating disorders are more significantly related to psychotic disorders than others

Evidence of absence: no relationship between behaviourally measured prediction error response and schizotypy

Introduction: The predictive processing framework has attracted much interest in the field of schizophrenia research in recent years, with an increasing number of studies also carried out in healthy individuals with nonclinical psychosis-like experiences. The current research adopted a continuum approach to psychosis and aimed to investigate different types of prediction error responses in relation to psychometrically defined schizotypy. Methods: 102 healthy volunteers underwent a battery of behavioural tasks including a) a force-matching task, b) a Kamin blocking task, and c) a reversal learning task together with three questionnaires measuring domains of schizotypy from different approaches. Results: Neither frequentist nor Bayesian statistical methods supported the notion that alterations in prediction error responses were related to schizotypal traits in any of the three tasks. Conclusions: These null results suggest that deficits in predictive processing associated with clinical states of psychosis are not always present in healthy individuals with schizotypal traits