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Self in Schizophrenia: Current issues and future directions

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Review Article

Self in schizophrenia: Current issues and future directions

Chandril Chandan Ghosh, Rajeshwari Muthukumaran
Department of Psychology, Christ University, Bengaluru, Karnataka, India

Abstract Background: The objective of this review is to discuss the current advancements, and critical issues, in the area
of studying disturbances of self in schizophrenia. The critical and systematic review of the self in schizophrenia is
significant because it has been regarded as a prodrome and a predictor of the development of future psychosis. In
addition, it has been found to be over and above clinical symptoms and is common in people with schizophrenia.
Methodology: A systematic electronic literature search was done using PubMed, MEDLINE, and PMC (PubMed
Central) databases were searched systematically, and relevant articles published in English peer-reviewed
journals were selected.
Results: The findings were discussed, and critical analysis of the studies revealed methodological and
conceptual issues in the literature studying self in schizophrenia.
Conclusion: The review has concluded with the discussion on future directions in terms of research and
clinical applications.

Keywords: Prodrome, schizophrenia, self

Address for correspondence: Mr. Chandril Chandan Ghosh, 2‑A, Syndicon Enclave, 25/1A/1, Naktala Road, Kolkata ‑ 700 047, West Bengal, India.
E‑mail: ghoshchandril@gmail.com

INTRODUCTION atypical self‑experiences or anomalies in the perception

Disturbances in the perception of self have been considered
as central to the development of, as among the first‑order
symptoms of, and as a significant predictor of psychosis.
As reviewed by Nelson, Thompson, and Yung[1] such
disturbances might include interrelated disturbances in
the sense of presence, corporeality, disturbed stream of
consciousness, existential reorientation, and self‑demarcation,
hence warranting more research in this area. For the empirical
research to benefit, the current review attempts to analyze and
critically evaluate the past, present, and future of this area of
research. It also suggests future directions toward the end.
Disturbances of self
In schizophrenia and its spectrum, the self is seen as
constantly challenged, incoherent, and unstable causing
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of self and others, which manifests itself as one having
a feeling of not completely existing (identity distortion),
reduction in the feeling of complete awareness of
experiences (which is the reduction of “mine‑ness” and
self‑affection) and reduction in feeling privy to their
inner experiences, and at the same time extended and
concentrated self‑reflection (hyper‑reflexivity). With
respect to thoughts especially, multiple train of thoughts
with different contents crossing over (thought pressure)
can also be found which often lead to mental fatigue in
individuals with schizophrenia.[2,3] Another demonstration
of hyper‑reflexivity is difficulty in bringing the two
aspects of thought together, which are the meaning and
the internal image/inner speech (signifier), which leads
to reduction in the automaticity of the full awareness of
one’s own thought (disturbance of mine‑ness). Thus, this
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DOI:
10.4103/AMH.AMH_12_18 How to cite this article: Ghosh CC, Muthukumaran R. Self in schizophrenia:
Current issues and future directions. Arch Ment Health 2018;19:102-10.

102 © 2018 Archives of Mental Health | Published by Wolters Kluwer ‑ Medknow

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Ghosh and Muthukumaran: Self in schizophrenia
minimal self‑disturbance (other) serves as the median
between normal experience and Schneider’s first‑rank
symptoms (that is, between normal inner speech and
auditory hallucinations – German: Gedankenlautwerden).[4]
Therefore, self‑disorder becomes a “way of being”
distorting one’s relation with the reality, thus preceding
psychosis mainly.[5,6] Although such experiences can be said
to be common for broad psychotic spectrum, the presence
of intense self‑distortion and other boundary distortion
along with the intense reduction in minimal self‑experience
are said to be very specific to schizophrenia.[7] This is clearly
observed from inconsistent cognitive performance.[8]
Clinical application
Fundamentally, a hypothesis of psychotic symptoms, in
general, has been said to be explained by the disorganization
of perception and trouble in multi‑sensory integration
which leads to phenomenologically disturbed grip of reality
along with hyper‑reflexivity and diminished self‑affection
which affects the totality of self‑world interaction,[6,9] which
aids in understanding the nature of psychosis as such.
The diagnostic importance of understanding self
‑disturbances is essential as clients generally have difficulty
verbally stating the disturbances spontaneously.[10,11] This
happens also because awareness of such distortions in
self is less.
Therefore, vague complaints make it vital for a clinician as
Parnas et al.[12] stated to be acquainted with the ability to
search for the “nonspecific specificity.” Research showed
that self‑disorders play a predictive function as well as
aided in identification of at‑risk population for psychotic
spectrum disorders,[1,13] suicidal ideation (although the
presence of depressive feature is key),[14] and preliminary
social disturbances (with either schizophrenic or bipolar
psychosis).[15]
Self‑disorder is said to cause more distress than
psychosis.[2] The “passive” nature of this disturbance
and this being the reason behind reduced insight,[3,5]
along with the above‑mentioned clinical applications,
has led to the proposal of adding self‑disorder as a
symptom in the forthcoming International Classification
of Diseases‑11.[16]
Controversies
Lysaker and Lysaker[17] proposed Ich‑Störung or ego
disorder based on the failure to disprove minimal
self as an explanation for self‑disorder and that
boundary between oneself and others is disturbed.
Archives of Mental Health | Volume 19 | Issue 2 | July-December 2018
Therefore, the viewpoint by  Sass and Parnas that the
core facet of schizophrenia is the solipsism [6] and
arising disturbances in social relations.[18] Parnas and
Henriksen[5] acknowledged this but said that the levels
of self exist rather than focusing on just the minimal
self. Thus, upcoming researchers can expand their
focus to include Examination of Anomalous World
Experience, rather than just examination of Anomalous
Self‑Experience (EASE), incorporating time, space,
social aspects, and cognition (language especially, as
it has been related to the verbal expression of self) to
conceptualize  it as a “presence of disturbance.”[17]
Treatment of self‑disturbances
For treating self‑disturbances, considering the fact
that the validation of self‑disorders is controversial
and the disturbances are myriad, treatments are
more broad‑spectrum oriented. One of which is the
body‑oriented psychological therapy which helps
integrating self‑increasing self‑direction emotional
management (expression especially) and enhancing social
interactions.[19] The neurocognitive correlates of aberrant
salience (memory and attention mainly) are said to be
managed by the use of antipsychotics as the biological basis
of it has been related to dopamine excess. Then again, there
exists a risk of dampening of other relevant internal and
external stimuli,[20,21] especially with reference to volition and
attention, thus heading toward negative symptomatology
of schizophrenia. On a related biological note, the presence
of abnormal myelination in fascicule (ones projecting
frontally), long‑term potentiation (N‑methyl‑D‑aspartate
receptors), and biology of memory functions have shown
to be promising future directions.
Development of relation between self and schizophrenia
This section looks into the conceptual understanding of
the configuration (Gestalt or pattern) of a sense of self
in individuals with schizophrenia and their implications in
the realms of psychiatric care, treatment and management,
and most importantly research developed. Schizophrenia
symptoms are broadly categorized as positive, negative,
and disorganized symptoms.[22] Nevertheless, starting
from Bleuler, who considered that a core facet in
“dementia praecox,” is a disturbance in self and splitting
of mind, the current studies also point that persistent and
intense aberrations in self‑experience[5] are to be a crucial
domain because of which this disorder is also termed
as a self‑disorder fundamentally. Initially, schizophrenia
was distinguished from other psychotic disorders such
as manic‑depressive psychosis and dementia praecox.
After Kraepelin[22] delineated it from general paresis,
which was a major milestone in limiting the clinical
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Ghosh and Muthukumaran: Self in schizophrenia
syndrome by another etiopathophysiological model, Freud
regarded schizophrenia as deriving from psychological
development arrested before the Oedipal stage, that is the
development of an integrated ego. According to Freud,
this arrest severely compromised the schizophrenic
patient’s capacity to relate and rendered psychoanalytic
treatment problematic, if not impossible. Kircher and
David[23] (2003) call self as the continuous source of
internally generated input consisting of the prereflective
aspect (which precedes the explicit awareness of “I”)
of self and Western literature call it as autonomous,
free, and in control. Neitzsche[23] (1966) following an
existential viewpoint considers self as a “subjective
multiplicity” composed by a social structure involving
an ensemble of phenomenological descriptions of
interanimating parts. This is why narratives are considered
to encompass and sufficiently help build the structure
of self according to the dialogical standpoint, which
brings, as Dewey[22] posited, language (cognition) into
the picture. Oyserman[24] (2001) defined self as a system
that contains self‑relevant knowledge which acts as a tool
in extracting meaning and organizing experiences to aid in
defending and constructing a whole‑functioning identity
for the organism which is called as the self‑concept. This
contains experiential and abstracted information which is
self‑relevant and serves as a yardstick of self‑evaluation
or verification for the organism to build on one’s
self‑efficacy and worth. Self has been considered to
develop after interactions with the society, the mode
of interaction seems bidirectional because, how one
perceives the society depends on of how the (social)
self interprets the perceived information, at the same
time, social constructivists suggest that an individual’s
relationship with the society. The mode of interaction
is what leads to the construction of self‑structure. The
latter was supported by Harlow [24] (1965), who said
that social isolation in monkeys led to the absence of
development of awareness of self. The content of
the self has been said to have self‑related schemas or
mental maps, and the cause on the consequence of
cognition (most primitively language) is self. The nativist
theme by Chomsky[22] (1965) indicates that the inherent
linguistic learning abilities help in understanding the world
around oneself, which in turn affects one’s perception
of experience. Affirming this, Neitzsche (1974) claimed,
“consciousness has developed only under the pressure
of the need for communication.”[22] Thus, a smooth
flow between interacting perspectives of existentialism,
phenomenology, social constructivism, and cognition
can be seen which try to explain the ontological and
epistemological construct and purpose of self.
104
Aims of the study
This chapter aimed at reviewing and examining the
available literature about the self in schizophrenia. The
purpose was to introduce the topic, reinstate its historical
development, present directions of research, and update
the literature body in this area, with this abundance of
information, pointing toward future directions in research
and implications of the overall findings.
METHODOLOGY
Strategies to search and select studies
An electronic literature search was carried out on PubMed
Central and PubMed databases to explore English
articles, published in peer‑reviewed journals exploring
self‑associated with schizophrenia. For detecting the
potentially useful papers, a combination of keywords such
as “self and schizophrenia” and “psychosis and self ” was
used. Other relevant reviews and meta‑analyses on related
topics, along with the references from retrieved papers,
were screened to identify more studies.
Measures
The reviewed studies had taken into consideration a
wide range of participants regarding its nature, size, and
methods of selecting them and findings. Incorporated
studies used the following scales to measure different
aspects of self: minimally prompted self‑descriptions,
qualitative narratives, The Assessment of Self Descriptions
Manual, EASE, Inventory of Psychotic‑Like Anomalous
Self‑Experiences (IPASE), Self‑Esteem Scale, [25] and
Self‑Concept Clarity Scale[26] and “self is ill” subscale of
Personal Beliefs about Illness Questionnaire.[27]
Selection of studies
The inclusion of the studies did not have any criterion
concerning the sample or use any specific inventories or
questionnaires. The relevance of the studies was estimated
regarding whether they are linking self with schizophrenia
or at‑risk psychosis in any way.
Study and participant characteristics
The eleven studies included a schizophrenia sample in
outpatient and outpatient services (649 subjects),[28-31]
at‑risk individuals for psychosis (148 subjects)[32,33] (Hoever,
Klien, Altinayazar and Metz, 2013), siblings of healthy
controls (56 subjects)[32] (Irarravazhal, 2013), and healthy
controls (1117 subjects). All of the studies used a
sample of both male and female genders. Many studies
included interviews[3] and other qualitative aspects such
as narratives.[33]
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Ghosh and Muthukumaran: Self in schizophrenia
REVIEWED LITERATURE
Self and schizophrenia
From the initial years when schizophrenia had first begun,
it has always been portrayed as one in which there is
confusion regarding the self as depicted in the “splitting
of psychological operations: The disorder becomes vivid
and personality fails to retain its solidarity” Bleuler.[20]
When there is fading of the boundaries between self and
other, it is known as “first‑rank symptoms.” When the
concept of self becomes distorted and the distinction
between self and others becomes obscure, it brings
about the key understanding of schizophrenia that
ultimately causes other symptoms.[6] Various cases of
self‑disorder symptoms include when the boundaries
between self and the world become indistinct or where
there is difficulty recognizing experience from memory
or fantasy or feeling that the psyche does not dwell
well inside the body.[34] These indications represent the
inability to accurately distinguish self‑created activities
and considerations because of an unsettling influence in
the handling of data identifying with self versus other.
In spite of the fact that the pertinence of self‑disorders
is entrenched in the phenomenological writing[12,6,7], there
is generally little information of their organic and mental
underpinnings.
The EASE[10] aims to survey encounters or experiences
of self‑disorder by means of a clinical interview and a
rating of an elucidating psychopathological checklist
with 57 things. It is a 4‑point Likert scale where
0 = absent, 1 = present (mild), 2 = present (moderate), and
3 = present (severe). Other than EASE other methods of
assessments were used for schizophrenia and other major
disorders which may include Bonn Scale for the Assessment
of Basic Symptoms.[35] Examination of such patients might
be constrained by medicine and the large number of various
useful hindrances found in numerous patients. Self‑disorder
side effects have been seen in individuals who are at high
risk for psychosis,[1] and encounters indicate customarily
considered markers of schizophrenia possibly found in
clinical populace used in other researches as well.[36,37] There
is a developing agreement that psychotic symptoms exist
on a continuum.[38] Past reviews on self‑disorder side effects
have observed these manifestations to be predominant
among help‑looking for youths, which gives support to
the utilization of these side effects in early identification
of risk for schizophrenia.[39]
The ipseity (first person view of world or subjectivity)
disturbance model, as discussed by Sass and Pamas[40] is
Archives of Mental Health | Volume 19 | Issue 2 | July-December 2018
where disturbances in the sense of self occurred due to
disruptions in organizing one’s subjective experiences
in one’s consciousness, which leads to maintaining
individuality, and this can be used to explain many of the
symptoms experienced by individuals with schizophrenia.[18]
Two complementary distortion concepts stemming from
this theory are (1) hyper‑reflexivity, wherein the implicit
aspects of self appear salient and thus something normally
implicitly understood becomes focal and explicit; and
the other concept being (2) diminished self‑affection,
wherein the implicit aspects of self are diminished and not
experienced completely in the array of self‑consciousness,
that is what is normally tacit is not a taken‑for‑granted
selfhood. That is, the normally inalienable aspect of self,
due to disruption in self‑consciousness, is not perceived as
a part of self. Barry[41] noted that although self‑disturbances
occur, it does not tend to affect the self‑referencing aspect
of “I;” thus, this aspect of self‑coinciding subjectivity
of experience or the basic self (ipseity) is intact, which
contradicts the preexisting viewpoint that the awareness
of self‑presence, the “I,” has no precise meaning to the
individual.[42] These concepts try to explain psychosis on
phenomenology as the model mentioned above assumed
these distortions to be happening at the prereflective
level and are considered as the phenotypic trait markers
for the schizophrenia spectrum. Some studies tried to
delineate the differences in disruptions of self among
individuals with schizophrenia and with psychosis and
to suggest that such differences can be found by the
extent of disruptions and pervasiveness of it in different
domains of self. Sass and Borda[8] affirmed the preexisting
hypothesis that disruptions in sense of self do happen in
individuals with schizophrenia than in healthy controls.
They also showed that these disruptions differed from
others with psychosis (in bipolar disorder) as those with
schizophrenia had main disruptions in the domains of self
as an agency (levels of self‑definition) and relatedness to
others (formation of personal relationships). However, they
also reported that similarities, especially in self‑definition
and quality of expression of relatedness, in the distortions
indicate a blur in this differentiation bringing in disruption
of self in schizophrenia into the broad domain of
psychosis and psychopathology. The sense of agency and
sense of ownership of oneself are sometimes differentiated
by researchers such as Parnas[2] and that both these aspects
are disturbed in the case of psychosis. However, Klien,
Altinayazar, and Metz[33] reported that self‑knowledge of
personality traits is reasonably accurate and reliable, reliable,
indicating that few core aspects such as information
regarding self (constituting the Gestalt) might appear to
be unperturbed in schizophrenia.[43] Another perspective
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Ghosh and Muthukumaran: Self in schizophrenia
breaks down self as the minimal self which is the
first‑person experiences, that is, being aware of oneself as a
subject of immediate and spontaneous experience, and this
is considered as the elementary unit of self.[44] Therefore,
self has more nonverbal aspects to it than what can be got
from verbal narratives as those are mainly reflective and
narrative self‑aspects. Therefore, understanding distortions
in the sense of self here is an alteration in the stream of
consciousness, especially disturbances in the self‑world
boundary, corporeality, and a sense of “mine‑ness”
or Meinhaftigkeit of experience,[13] therefore a lack of
prereflective meaning formation for those experiences. Not
only does minimal self‑disturbances show marked difference
among individuals with bipolar disorder and schizophrenia,
but the degree of distortion has also been related to the
severity of certain symptoms in schizophrenia such as
suicidal behaviors (Martin et al., 2014). Although cognitive
impairments are a characteristic feature of schizophrenia,
no correlation between minimal self‑disturbances and the
former has been found.
Moving to the sociocognitive perspective as followed
by Neis [32] the anomalous self‑experience (ASE) is
nothing but another term for the disturbances in self.
Moreover, this self‑experiential aspect along with other
symptoms of schizophrenia explains the interferences
and disruptions in cognitive experiences of individuals
with psychosis. The interesting finding posited was
that the emotional domain seems to be affected by the
self‑disturbances, that is, in using emotions (executive
functioning of self), ASEs played a predictive role;
however, in perceiving and managing emotions (internal
integration and processing functions), positive symptoms
of psychosis appeared to have played a predicting role.
The various examples of ASEs consist of those relating
to cognition, consciousness, depersonalization, alienation
of self, and distortions with respect to understanding
meanings. [2] The various positive, negative, and
disorganized psychotic symptoms in schizophrenia are
said to be caused by such ASEs.[6] In a previous study,
the results showed relations among patients who had
schizophrenia and ASEs.[6] There were relations between
suicidality and ASEs[44] along with a continued period
of psychosis that is not treated (duration of untreated
psychosis),[35] social dysfunction,[15] and trauma during
childhood in women.[45]
Nelson, Whitford, Lavoie and Sass[46] have, however,
reiterated the two previously mentioned concepts
of hyper‑reflexivity and diminished self‑affection in
neurocognitive terms as aberrant salience (in memory
and attention) and source monitoring deficits, respectively.
106
Therefore, the object‑oriented quality of awareness which
acts as the center of experiential gravity is disrupted by
these opposing forces causing the overall structure of
consciousness and its organization to be disrupted. After
the prediction error model based on belief system of
the individual being the origin of psychosis, the ipseity
in issues of source monitoring arises from problems in
differentiating between endogenous and exogenous stimuli
wherein mainly the difference lies on the controllability
and predictability of the former as it is self‑generated and
individuals with psychosis will not be having the usual
dampening response or attenuation of perception to
these endogenous stimuli, which is normal, and functional
magnetic resonance imaging studies also indicate problems
in memory, attention, and organizational sequencing to be
predicting this. Moreover, these self‑monitoring deficits
were consistent with those who had self‑other boundary
disruptions. Moreover, Nelson[46] identified this as related
to the compensatory hyper‑reflectivity where the individual
tries to identify the experiences as belonging to oneself
and due to a reduction in self‑affection. The aberrant
salience aspect, especially in the form of memory and
prediction of meaning function, has been understood as
processing of information taking place not only based
on perception but also based on integrating fragments
to form a working model, which usually occurs at a basic
automatic level, which can be disrupted in individuals with
schizophrenia because of neuro‑anatomical and functional
abnormalities. Thus, a weakening of prediction processes
which has also been predicted to occur due to excessive
attention to irrelevant cues and also has shown a positive
correlation with positive symptoms, altogether suggesting
a common disruption in information processing in its
fluidity and automaticity. It is important to note that both
self‑other interactions (as discussed above) and private
interactions (especially on a stream of consciousness)
show disturbances.
The self is not only restricted to the past experiences and
present spontaneous perception but also restricted to
mental time travel to the future to form a whole‑coherent
self‑representation. The past experiences can be summed
up in autobiographical memory and future through the
imagination of plausible both together serve as self‑function
by forming and maintaining one’s sense of self and
identity. These memories can be self‑relevant and are
termed as self‑defining memories and studies[30] suggest
that although this memory recall of healthy controls and
individuals with schizophrenia were the same, the content
of recalled memory was more about stigmatization
and hospitalization. Another study, however, presented
contradictory evidence that positive future projected events
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Ghosh and Muthukumaran: Self in schizophrenia
are more recalled by individuals with schizophrenia.[46]
Snyder[47] speaks of self‑awareness created by these memories
to be like a “double‑edged sword,” wherein understanding
of one’s illness and others’ reaction is even though crucial
to gain higher level insight, can also bring despair as the
“insulation” has been stripped away. The self's explanation
for the cause of the 'illness, which contributes towards
insight level is crucial to determine adherence to treatment
regimen and prediction of prognosis, appears to be mostly
external (that is, problem is caused by something outside
the body and not stemming from within, indication level
4 insight). This can also be interpreted as lower abilities to
reflect on self.[48] There has also been evidence suggesting
impairments in imagining future episodic events (called the
self‑defining future projections) and in preexperiencing
future events, such as presence of impairments in
experiencing anticipatory pleasure but not consummatory
pleasure,[43] despite anhedonia being an important feature in
schizophrenia. This inability forms an integrative construct
involving the future, thereby affecting the goal‑directed[45]
behaviors and thus affecting the personal continuity of the
sense of self. Furthermore, self‑defining future projections
also contribute to building of self‑concept with respect to
one’s identity, but a study indicated that individuals with
schizophrenia (when compared to healthy controls) extracted
less meaning from such preexperiences, indicating reduced
reasoning abilities which affect the current perception of
experiences contributing to building of self, but the level of
emotional valence and self‑referential material is comparable
with the healthy control group.[45]
Other facets of self have also been studied to enhance a
holistic awareness of disturbances in self. Weinberg and
collegues[49] found that quality of life with schizophrenia
was linked to self‑esteem instability and decreased
self‑concept clarity. Furthermore, depression among them
affected their self‑esteem. Self‑concept clarity was also
associated with an increase in positive symptoms and clarity
of self‑etiology. In addition, self‑stigmatization serves as a
major stressor for individuals with illness; however, when
self‑concept clarity is currently perceived, vulnerability to
stigmatization and stress caused by it is attenuated.[49]
Affirming Snyder’s view on self‑awareness, this study
posited that self‑concept clarity can be a risk rather than
resilience, which can lead to heightened self‑focused
attention, therefore leading to excessive processing and
awareness of internal cues[50] and hyper‑reflexivity.
To conclude, the ipseity model has been widely used to
explain the distortions in self widely whose neurocognitive
correlates have been brought out to attention recently.
Archives of Mental Health | Volume 19 | Issue 2 | July-December 2018
Although clear differences in distortions of self in
schizophrenia and other psychotic disorders are not
clear, researchers consider that the aberrance in self is
the underpinning for the disorders. Different viewpoints
understand the quality, intensity, and domains of self
being affected differently, but all commonly agree upon
the point that the narratives are an explicit understanding
of these distortions which occur in the phenomenological
spree of reality.
Measuring self
One of the interesting avenues for research with regard
to studying “self ” is the measurement of it. Symptoms of
schizophrenia and psychosis can be said to have well been
measured by tools such positive and negative syndrome
scale; however, for measuring aspects of self, there has
been no one single measure used. Wherein to start with,
the definition and domains of self can be seen from
different perspectives, and therefore, phenomenologically,
if one assumes that narratives can be used to measure
the prereflective aspect of sense of self, then minimally
prompted self‑descriptions, based on the ipseity model,
can be used. This idea of using narratives to capture the
essence of psychosis and disruptions in self in a tangible and
comprehensible manner commenced from Snyder’s[47] work
on their experiences of schizophrenia in a written literature
format, although these were in a retrospective format.
Another method being the assessment of self descriptions
manual is also used as it clearly gives different dimensions of
relatedness to others, sense of agency, modes of description
of the self, and integration of the self clearly. Other than
these description‑based tools, Parnas[12] used the EASE,
another phenomenology‑oriented instrument catering to
the exploration of minimal self‑disturbances. Cicero’s[32]
IPASE has been used recently as well. The self‑system has
different aspects which are measured individually such as
the Self‑Esteem Scale[25] and Self‑Concept Clarity Scale.[26]
Self‑etiology had been measured using interview techniques
to ascertain insight and also using “self is ill” subscale of
Personal Beliefs about Illness Questionnaire.[27]
DISCUSSION
Conceptual issues
The first issue that came across was that of defining the
term “self ” itself. Different researchers have conceptualized
self differently.
Second, although schizophrenia research can at times seem
to be characterized by a veritable explosion of empirical
findings, the diagnostic boundaries and pathogenetic
mechanisms of the disorder remain obscure. The lack of
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Ghosh and Muthukumaran: Self in schizophrenia
integration across “levels” of inquiry (phenomenological,
psychological, neurocognitive, neurobiological, genetic)
may contribute to this situation. Integration across
these levels may help researchers move toward unifying
principles and themes in the study of schizophrenia, which
will ultimately guide diagnosis, intervention, and early
identification practices.
Third, the term “schizophrenia” on which most of the
studies have been done is considered as too vague and
heterogeneous by many researchers to be considered
as a “single disorder.” Hence, the way schizophrenia is
conceptualized is another issue. Different individuals
diagnosed with schizophrenia may manifest and experience
the symptoms quite differently. Therefore, the key
diagnoses of schizoaffective disorder, delusional disorder,
and schizophrenia have been said not to represent
single‑independent disorders. Moreover, within these
categories of diagnosis is the accumulation of several
independent experiences, such as hallucinations, paranoia,
grandiosity, anhedonia, and thought disorder.[22]
Methodological issues
Methodological issues include the nature of participants
studied and assessments utilized to collect data. Types of
participants included in the reviewed studies while collecting
data included mainly those diagnosed with schizophrenia.
However, the validity of information collected from
schizophrenia patients is questionable because as discussed
before “schizophrenia” has multiple etiologies and
manifestations. Ten people suffering from schizophrenia
might have ten different ways of subjective experiences and
problems. Hence, we cannot treat all individuals diagnosed
with schizophrenia as homogenous group.
Measures/tools (assessment)
Owing to the importance of self in understanding
psychosis, researchers are currently trying out several ways
of measuring ASEs and other aspects of self. However,
issues regarding the methodology used to assess self are
a matter of debate.
Individuals at risk or experiencing psychosis might have
a distorted sense of self and have been considered to be
central to the development of psychosis;[32] hence, utilizing
self‑report measures, for example, IPASE,[32] might not
give empirically valid information even though it may
display strong psychometric qualities. Hence, finding out
alternative approaches is methodologically significant. These
alternatives can be used in addition to or independent of the
self‑report measures in the future research studies to obtain
internally consistent, stable, and clear responses.
108
One recent study by Cicero et al.,[32] in an attempt to
overcome the limitations of self‑report inventories, has
used a behavioral measure of self‑concept clarity, the Me
Not‑Me Decision Task, which is designed to measure
self‑concept clarity without the limitations of self‑report
measures, and thus presents an idea of developing and
applying a behavioral measure of assessing self in this
area of study. However, Ghosh[51] pointed out that the
behavioral task is not without limitations. Limitations might
include issues with clarity (subjective interpretation of the
terms “beautiful,” “nice,” etc.) and dimensionality (i.e., no
one is either of the two extremes, for example, no one is
nice or mean in all place, time, situations with everyone).
Therefore, such “black‑and‑white categorization” about
self might not have high objectivity and the “alteration”
might be more prone to affect fluctuations (for example,
when the patient is in elevated state, he/she might respond
to being beautiful, and while the patient is in depressed
state, he/she might respond to being ugly; these applies
to general population too). Moreover, there is no valuable
theoretical backup to support on what basis the adjectives
were chosen, therefore requiring an alternative behavioral
measure to be considered for measuring self‑concept clarity.
Thus, alternatives to self‑report approaches could be
an observer’s report (with every possibility of biased
responses from the observer, of course). Recently,
Nelson, Whitford, Lavoie, and Sass[46] have noted that
the measures of neurocognitive disturbances of source
monitoring deficits and aberrant salience (such as binocular
depth inversion, perceptual closure, learned irrelevance,
spurious messages from noise, mismatch negativity,
salience attribution, reversal learning tasks, and temporal
binding tasks) and phenomenological disturbances of basic
self‑disturbances (such as the EASE instrument) may prove
to enhance the identification of “true positives” within
cohorts at high risk of psychosis. These neurocognitive
and phenomenological disturbances may assist in the
identification of people at highest risk of developing
schizophrenia and other psychotic disorders.
FUTURE DIRECTIONS AND RECOMMENDATIONS
Further investigation of self in schizophrenia holds
promise in terms of facilitating assessment and treatment
of psychosis. In spite of insurmountable research done
in schizophrenia, the diagnostic boundaries and the
pathogenic mechanisms of the disorder still remain
unclear. There is a lack in the reconciliation of the various
“levels” of inquiry which would otherwise help in early
detection, intervention, and diagnosis. In another recent
study conducted by Nelson, Lavoie and Sass[30] it has been
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Ghosh and Muthukumaran: Self in schizophrenia
seen that the detection of “true positives” is augmented
by certain measures of neurocognitive disturbances of
source monitoring deficits and aberrant salience as well
as phenomenological distortions. These also guide in
recognizing people who are at highest risk of developing
schizophrenia or other severe psychotic disorders
later. The ASEs also help in knowing more about the
symptoms related to self‑esteem and depression which
could assist in averting suicidality in these groups of
patients. More studies need to be conducted to treat
self‑disturbances. These avenues hold promise for
researchers and clinicians.
As of now, neither we know whether the neurocognitive
and phenomenological disturbances of self are a trait
or a state, nor we have much information to note the
variance by changes of orientation, attentional attitude,
action‑orientation, or motivational state. Many such
questions prevail and need further research.
Attention disturbance is a major aspect in schizophrenia,
delusions, and hallucinations being associated with inward
directed attention.[52] On the other hand, Nelson, Whitford,
Lavoie, and Sass [46] pointed out that the anomalies
associated with basic self‑disturbance are associated with
failed suppression of attention to irrelevant or familiar
information or stimuli in the environment. This failed
suppression might be associated with failure to suppress
excessive inward attention. If so, then hypothesizing high
inward directed attention as a part of self‑disturbances
found in schizophrenia, we propose treatment approach
to facilitate turning the attention outward. Such therapies
might involve refocusing cognitive and emotional
awareness toward the physical reality. A treatment module
involving making the individual more aware of physical
sensations (i.e., warm, cold, tense) by subjecting them to
different objects with precautionary measures, making
them engage in regular physical exercises, biofeedback
to be externally aware of internal body functioning, and
body‑oriented exercises as in body‑oriented psychological
therapy can be included. Since, malfunction is in the
hippocampus and related area, the “comparator” system
in schizophrenia, proposed that such dysfunction results
in an automatic, hyper‑reflexive awareness that disrupts
the tacit/focal structure essential to normal experience
and in particular, to the normal experience of basic
selfhood. Hence, the effect of such therapy on the
comparator system can be studied through neuroimaging
techniques to see if and how it influences the system and
its functions related to comparing predicted stimuli (“the
next expected state of the perceptual world” and stimuli
actually received).[46]
Archives of Mental Health | Volume 19 | Issue 2 | July-December 2018
CONCLUSION
The area of self‑disturbance in psychosis holds promise
to researchers, and clinicians in the field and more
investigations are needed to help professionals prevent,
predict, and treat psychosis.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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