Disturbance of Minimal Self (Ipseity) in Schizophrenia: Clarification and Current Status

Abstract

The assessment of psychopathology in most contemporary research is based squarely on signs and symptoms of disorder, often measured in fairly crude checklist-type fashion. This approach has tended to indicate significant overlap in psychotic and other symptoms across disorders, eg, between schizophrenia and bipolar disorder 1 and between psychotic disorders and borderline personality disorder. 2 This may partly be the result of the assessment tools and conceptual frameworks being used. By contrast, insights from phenomenological psychiatry and philosophy, focused on disturbed subjectivity, 3 indicate that disturbed self-experience or selfhood may underlie and generate many “surface-level” psychotic symptoms, particularly in schizophrenia spectrum disorders. There are many different meanings and controversies surrounding the notion of the “self.” 4 These controversies mainly concern its ontology or ultimate reality status, eg, as a kind of “substance,” object, or process. The experiential, subjective notion of the self (the sense of self) is, however, widely acknowledged, both in the analytic philosophy of mind 5 and in phenomenology. 6 Two levels of the experiential self are typically proposed: 1. “Minimal” self, also referred to as “basic” or “core” self or as “ipseity.” This is a prereflective, tacit level of selfhood. It refers to the implicit first-person quality of consciousness, ie, the implicit awareness that all experience articulates itself in first person perspective as “ my ” experience. In other words, all conscious acts are intrinsically self-conscious, 7 a feature sometimes designated as “self-affection.” “Minimal” or “core” self constitutes the foundational level of selfhood on which other levels of selfhood are built. 6–8 2. “Narrative” or social self. This refers to characteristics such as social identity, personality, habits, style, personal history, etc. Psychological concepts such as “self-esteem” or “self-image” refer to this level of selfhood. This level is widely understood to presuppose the sense of existing as a subject of experience (“minimal self”) and often involves reflective, metacognitive processes, in which one’s self is largely an object of awareness. 6 , 9 , 10 Many classic and early texts about schizophrenia proposed that disturbance of minimal self is at the core of the disorder, 11 , 12 a view reinforced and extended by recent empirical studies (see below). The ipseity-disturbance model (IDM), developed by Sass and Parnas, presents distortion/instability of the minimal self as consisting of 2 complementary aspects: hyperreflexivity and diminished self-affection. While hyperreflexivity refers to heightened awareness of aspects of experience that are normally tacit or implicit, diminished self-affection refers to a weakened sense of existing as a subject of awareness (see Henriksen and Parnas 13 and Parnas and Handest 14 for clinical and Sass and Parnas 15 and Sass et al16 for theoretical description). These processes necessarily disrupt a person’s “grip” or “hold” on the conceptual or perceptual field of awareness. The IDM posits that disturbance in the structure of experience, normally permeated by stable first person perspective, characterizes schizophrenia spectrum disorders. This instability manifests itself in a range of anomalous subjective experiences, typically already present in childhood or early adolescence, including forms of depersonalization, diminished sense of existing as a bodily subject, distortions of first-person perspective with weakened sense of “mineness” of the field of awareness (thoughts, sensations, etc.), diminished sense of coherence and consistency in fundamental features of self (eg, sense of anonymity, identity confusion, etc.), and disturbed self-other/self-world boundaries. 17 Being self-present and present in the world of others and objects (the self-world structure ) exist as 2 sides of the same coin. 18 Accordingly, minimal self-disturbance involves diminished attunement and immersion in the world, inadequate spontaneous grasp of self-evident meanings (perplexity, diminished “common sense”), and hyperreflectivity. The IDM provides a parsimonious way of understanding not only the evolution of psychotic symptoms and the often shifting expression of its single features (ie, why one symptom might recede and another become more prominent), 11 , 19 but also the profound transformations of subjectivity often reported in schizophrenia spectrum conditions. First-person accounts of schizophrenia are replete with descriptions of this form of self-disturbance. It is quite distinct from the disturbing impact psychotic illness can have on an individual’s sense of self (thus, more a trait-vulnerability factor than a reaction to psychosis). 20 A recent account of self-disturbance in schizophrenia 21 differs from the IDM in that it seems to characterize the disturbance as existing primarily on the level of the narrative self (level 2 above). That model