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 Table of Contents  
REVIEW ARTICLE
Year : 2018  |  Volume : 19  |  Issue : 2  |  Page : 102-110

Self in schizophrenia: Current issues and future directions


Department of Psychology, Christ University, Bengaluru, Karnataka, India

Date of Web Publication31-Dec-2018

Correspondence Address:
Mr. Chandril Chandan Ghosh
2-A, Syndicon Enclave, 25/1A/1, Naktala Road, Kolkata - 700 047, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AMH.AMH_12_18

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  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


How to cite this article:
Ghosh CC, Muthukumaran R. Self in schizophrenia: Current issues and future directions. Arch Ment Health 2018;19:102-10

How to cite this URL:
Ghosh CC, Muthukumaran R. Self in schizophrenia: Current issues and future directions. Arch Ment Health [serial online] 2018 [cited 2019 Jan 22];19:102-10. Available from: http://www.amhonline.org/text.asp?2018/19/2/102/248874




  Introduction Top


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 atypical self-experiences or anomalies in the perception 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 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. 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 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.

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 Top


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],[29],[30],[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]


  Reviewed Literature Top


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 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 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. 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 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. 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 Top


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 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.

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 Top


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 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]


  Conclusion Top


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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