Is Schizophrenia a Disorder of Consciousness? Experimental and Phenomenological Support for Anomalous Unconscious Processing.

Decades ago, several authors have proposed that disorders in automatic processing lead to intrusive symptoms or abnormal contents in the consciousness of people with schizophrenia. However, since then, studies have mainly highlighted difficulties in patients' conscious experiencing and processing but rarely explored how unconscious and conscious mechanisms may interact in producing this experience. We report three lines of research, focusing on the processing of spatial frequencies, unpleasant information, and time-event structure that suggest that impairments occur at both the unconscious and conscious level. We argue that focusing on unconscious, physiological and automatic processing of information in patients, while contrasting that processing with conscious processing, is a first required step before understanding how distortions or other impairments emerge at the conscious level. We then indicate that the phenomenological tradition of psychiatry supports a similar claim and provides a theoretical framework helping to understand the relationship between the impairments and clinical symptoms. We base our argument on the presence of disorders in the minimal self in patients with schizophrenia. The minimal self is tacit and non-verbal and refers to the sense of bodily presence. We argue this sense is shaped by unconscious processes, whose alteration may thus affect the feeling of being a unique individual. This justifies a focus on unconscious mechanisms and a distinction from those associated with consciousness.

Thought Insertion as a Self-Disturbance: An Integration of Predictive Coding and Phenomenological Approaches.

Current theories in the framework of hierarchical predictive coding propose that positive symptoms of schizophrenia, such as delusions and hallucinations, arise from an alteration in Bayesian inference, the term inference referring to a process by which learned predictions are used to infer probable causes of sensory data. However, for one particularly striking and frequent symptom of schizophrenia, thought insertion, no plausible account has been proposed in terms of the predictive-coding framework. Here we propose that thought insertion is due to an altered experience of thoughts as coming from "nowhere", as is already indicated by the early 20th century phenomenological accounts by the early Heidelberg School of psychiatry. These accounts identified thought insertion as one of the self-disturbances (from German: "Ichstörungen") of schizophrenia and used mescaline as a model-psychosis in healthy individuals to explore the possible mechanisms. The early Heidelberg School (Gruhle, Mayer-Gross, Beringer) first named and defined the self-disturbances, and proposed that thought insertion involves a disruption of the inner connectedness of thoughts and experiences, and a "becoming sensory" of those thoughts experienced as inserted. This account offers a novel way to integrate the phenomenology of thought insertion with the predictive coding framework. We argue that the altered experience of thoughts may be caused by a reduced precision of context-dependent predictions, relative to sensory precision. According to the principles of Bayesian inference, this reduced precision leads to increased prediction-error signals evoked by the neural activity that encodes thoughts. Thus, in analogy with the prediction-error related aberrant salience of external events that has been proposed previously, "internal" events such as thoughts (including volitions, emotions and memories) can also be associated with increased prediction-error signaling and are thus imbued with aberrant salience. We suggest that the individual's attempt to explain the aberrant salience of thoughts results in their interpretation as being inserted by an alien agent, similarly to the emergence of delusions in response to the aberrant salience of sensory stimuli.

Conscious brain, metacognition and schizophrenia.

Recent findings indicate that the binding and synchronization of distributed neural activities are crucial for cognitive processes and consciousness. In addition, there is increasing evidence that disrupted feature binding is related to experiences of disintegration of consciousness in schizophrenia. These data suggest that the disrupted binding and disintegration of consciousness could be typically related to schizophrenia in terms of Bleuler's concept of "splitting". In this context, deficits in metacognitive capacity in schizophrenia may be conceptualized as a spectrum from more discrete to more synthetic activities, related to specific levels of neural binding and neurocognitive deficits. This review summarizes the recent research on metacognition and its relationship to deficits of conscious awareness that may be found in schizophrenia patients. Deficits in synthetic metacognition are likely linked to the integration of information during specific processes of neural binding. Those in turn may be related to a range of mental activities including reasoning style, learning potential and insight.

Prognosis of Brief Psychotic Episodes: A Meta-analysis.

IMPORTANCE: The prognostic significance of competing constructs and operationalizations for brief psychotic episodes (acute and transient psychotic disorder [ATPD], brief psychotic disorder [BPD], brief intermittent psychotic symptoms [BIPS], and brief limited intermittent psychotic symptoms [BLIPS]) is unknown. OBJECTIVE: To provide a meta-analytical prognosis of the risk of psychotic recurrence in patients with remitted first-episode ATPD, BPD, BIPS, and BLIPS and in a benchmark group of patients with remitted first-episode schizophrenia (FES). We hypothesized a differential risk: FES > ATPD > BPD > BIPS > BLIPS. DATA SOURCES: The Web of Knowledge and Scopus databases were searched up to May 18, 2015; the articles identified were reviewed as well as citations of previous publications and results of a manual search of the reference lists of retrieved articles. STUDY SELECTION: We included original articles that reported the risk of psychotic recurrence at follow-up for patients in remission from first-episode ATPD, BPD, BLIPS, BIPS, and FES. DATA EXTRACTION AND SYNTHESIS: Independent extraction by multiple observers. Random-effects meta-analysis was performed, and moderators were tested with meta-regression analyses, Bonferroni corrected. Heterogeneity was assessed with the I2 index. Sensitivity analyses tested the robustness of the results. Publication bias was assessed with funnel plots and the Egger test. MAIN OUTCOMES AND MEASURES: Proportion of patients with baseline ATPD, BPD, BLIPS, and BIPS who had any psychotic recurrence at 6, 12, 24, and 36 or more months of follow-up. RESULTS: Eighty-two independent studies comprising up to 11,133 patients were included. There was no prognostic difference in risk of psychotic recurrence between ATPD, BPD, BLIPS, and BIPS at any follow-up (P > .03). In the long-term analysis, risk of psychotic recurrence (reported as mean [95% CI]) was significantly higher in the FES group (0.78 [0.58-0.93] at 24 months and 0.84 [0.70-0.94] at ≥ 36 months; P < .02 and P < .001, respectively) compared with the other 4 groups (0.39 [0.32-0.47] at 24 months and 0.51 [0.41-0.61] at ≥ 36 months). There were no publication biases. Sex and exposure to antipsychotic medication modulated the meta-analytical estimates (.002 < P < .03). CONCLUSIONS AND RELEVANCE: There are no prognostic differences in risk of psychotic recurrence between ATPD, BPD, BLIPS, and BIPS constructs of brief psychotic episodes. Conversely, there is consistent meta-analytical evidence for better long-term prognosis of brief psychotic episodes compared with remitted first-episode schizophrenia. These findings should influence the diagnostic practice and clinical services in the management of early psychosis.

Self-disturbances in schizophrenia: history, phenomenology, and relevant findings from research on metacognition.

With a tradition of examining self-disturbances (Ichstörungen) in schizophrenia, phenomenological psychiatry studies the person's subjective experience without imposing theoretical agenda on what is reported. Although this tradition offers promising interface with current neurobiological models of schizophrenia, both the concept of Ichstörung and its history are not well understood. In this article, we discuss the meaning of Ichstörung, the role it played in the development of the concept of schizophrenia, and recent research on metacognition that allows for the quantitative study of the link between self-disturbance and outcome in schizophrenia. Phenomenological psychiatrists such as Blankenburg, Binswanger, and Conrad interpreted the Ichstörung as disturbed relationship to self and others, thus challenging recent efforts to interpret self-disturbance as diminished pure passive self-affection, which putatively "explains" schizophrenia and its various symptoms. Narrative is a reflective, embodied process, which requires a dynamic shifting of perspectives which, when compromised, may reflect disrupted binding of the components of self-experience. The Metacognition Assessment Scale-abbreviated as MAS-A-suggests that persons with schizophrenia tend to produce narratives with reductions in the binding processes required to produce an integrated, embodied self within narrated life stories, and in interactive relationships with others.

Jaspers' critique of essentialist theories of schizophrenia and the phenomenological response.

This contribution reviews the fin de siècle and immediately following efforts (Berze, Gross, Jung, Stransky, Weygandt, and others) to find a fundamental psychological disturbance (psychologische Grundstörung) underlying the symptoms of dementia praecox, later renamed schizophrenia by Bleuler (1908, 1911). In his General Psychopathology (1913), Jaspers brings order into the field by bringing to psychopathology a scientific basis coupled with phenomenological rigor. He was critical of theories that proposed an essence of schizophrenia, which is merely asserted verbally. This imperative is reiterated by other members of the Heidelberg School (Gruhle, Mayer-Gross, and K. Schneider). Gruhle (1929) contended that the primary symptoms of schizophrenia, indicating an underlying but still unknown neurobiological disease process, are independent from one another. They cannot be brought under a single, current theoretical model. That is, schizophrenia cannot be explained in terms of a 'catchword', which is only thought but not empirically studied. Sobered but also inspired by Jaspers' rigor, phenomenological psychiatrists (Binswanger, Blankenburg, Conrad, Ey, and others) proposed more tempered models, which could be studied empirically or tested scientifically. This historical progression may be viewed as a dialectical process: First, bold, merely verbal assertions without method were made, then Jaspers followed with a sobering critique, and finally, the existential-phenomenological clinicians/researchers responded by producing fine-grained, rigorous phenomenological models, tempered by humility and self-critique, which led to hypotheses that could be tested in current clinical neuroscience.

The phenomenology and neurobiology of delusion formation during psychosis onset: Jaspers, Truman symptoms, and aberrant salience.

Following the publication of Karl Jaspers' General Psychopathology (1913), delusions have been characterized as being nonunderstandable in terms of the person's biography, motivations, and historical-cultural context. According to Jaspers, this loss of understandability is due to an underlying neurobiological process, which has interrupted the normal development of the individual's personality. Inheriting the 19th-century division between the natural- and human-historical sciences, Jaspers emphasizes the psychological understanding of mental disorders as narrative-based, holistic, and contextual. By doing so, he embraces cultural, ethnic, and individual differences and anticipates a person-centered medicine. However, he also affirms the value of explanatory neurobiological approaches, especially in the research and diagnosis of delusions. The phenomenological approach leads to neurobiological hypotheses, which can be tested experimentally. The present article addresses these issues by illustrating Jaspers' fundamental contribution to current neurobiological research concerning the formation of delusions during early phases of psychosis. Specifically, we present delusional mood and Truman symptoms as core phenomenological features at the origin of psychosis onset, and we discuss their neurobiological substrate with the aberrant salience and dopamine dysregulation models. Jaspers and his successors' phenomenological approach suggests that delusion is formed through loss of context in its experiential-perceptual origins. This is consistent with the more recent neurobiological models.

The six most essential questions in psychiatric diagnosis: a pluralogue. Part 4: general conclusion.

In the conclusion to this multi-part article I first review the discussions carried out around the six essential questions in psychiatric diagnosis - the position taken by Allen Frances on each question, the commentaries on the respective question along with Frances' responses to the commentaries, and my own view of the multiple discussions. In this review I emphasize that the core question is the first - what is the nature of psychiatric illness - and that in some manner all further questions follow from the first. Following this review I attempt to move the discussion forward, addressing the first question from the perspectives of natural kind analysis and complexity analysis. This reflection leads toward a view of psychiatric disorders - and future nosologies - as far more complex and uncertain than we have imagined.

The six most essential questions in psychiatric diagnosis: a pluralogue part 3: issues of utility and alternative approaches in psychiatric diagnosis.

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM - whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part 1 of this article took up the first two questions. Part 2 took up the second two questions. Part 3 now deals with Questions 5 & 6. Question 5 confronts the issue of utility, whether the manual design of DSM-III and IV favors clinicians or researchers, and what that means for DSM-5. Our final question, Question 6, takes up a concluding issue, whether the acknowledged problems with the earlier DSMs warrants a significant overhaul of DSM-5 and future manuals. As in Parts 1 & 2 of this article, the general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances.

The six most essential questions in psychiatric diagnosis: a pluralogue part 2: Issues of conservatism and pragmatism in psychiatric diagnosis.

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM--whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article took up the first two questions. Part II will take up the second two questions. Question 3 deals with the question as to whether DSM-V should assume a conservative or assertive posture in making changes from DSM-IV. That question in turn breaks down into discussion of diagnoses that depend on, and aim toward, empirical, scientific validation, and diagnoses that are more value-laden and less amenable to scientific validation. Question 4 takes up the role of pragmatic consideration in a psychiatric nosology, whether the purely empirical considerations need to be tempered by considerations of practical consequence. As in Part 1 of this article, the general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances.

The six most essential questions in psychiatric diagnosis: a pluralogue part 1: conceptual and definitional issues in psychiatric diagnosis.

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM - whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article will take up the first two questions. With the first question, invited commentators express a range of opinion regarding the nature of psychiatric disorders, loosely divided into a realist position that the diagnostic categories represent real diseases that we can accurately name and know with our perceptual abilities, a middle, nominalist position that psychiatric disorders do exist in the real world but that our diagnostic categories are constructs that may or may not accurately represent the disorders out there, and finally a purely constructivist position that the diagnostic categories are simply constructs with no evidence of psychiatric disorders in the real world. The second question again offers a range of opinion as to how we should define a mental or psychiatric disorder, including the possibility that we should not try to formulate a definition. The general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances.

No departure to "Pandora"? Using critical phenomenology to differentiate "naive" from "reflective" experience in psychiatry and psychosomatic medicine (a comment on Schwartz and Wiggins, 2010).

The mind-body problem lies at the heart of the clinical practice of both psychiatry and psychosomatic medicine. In their recent publication, Schwartz and Wiggins address the question of how to understand life as central to the mind-body problem. Drawing on their own use of the phenomenological method, we propose that the mind-body problem is not resolved by a general, evocative appeal to an all encompassing life-concept, but rather falters precisely at the insurmountable difference between "natural" and a "reflective" experience built into phenomenological method itself. Drawing on the works of phenomenologically oriented thinkers, we describe life as inherently "teleological" without collapsing life with our subjective perspective, or stepping over our epistemological limits. From the phenomenology it can be demonstrated that the hypothetical teleological qualities are a reflective reconstruction modelled on human behavioural structure.

Kafka, paranoic doubles and the brain: hypnagogic vs. hyper-reflexive models of disrupted self in neuropsychiatric disorders and anomalous conscious states.

Kafka's writings are frequently interpreted as representing the historical period of modernism in which he was writing. Little attention has been paid, however, to the possibility that his writings may reflect neural mechanisms in the processing of self during hypnagogic (i.e., between waking and sleep) states. Kafka suffered from dream-like, hypnagogic hallucinations during a sleep-deprived state while writing. This paper discusses reasons (phenomenological and neurobiological) why the self projects an imaginary double (autoscopy) in its spontaneous hallucinations and how Kafka's writings help to elucidate the underlying cognitive and neural mechanisms. I further discuss how the proposed mechanisms may be relevant to understanding paranoid delusions in schizophrenia. Literature documents and records cognitive and neural processes of self with an intimacy that may be otherwise unavailable to neuroscience. To elucidate this approach, I contrast it with the apparently popularizing view that the symptoms of schizophrenia result from what has been called an operative (i.e., pre-reflective) hyper-reflexivity. The latter approach claims that pre-reflective self-awareness (diminished in schizophrenia) pervades all conscious experience (however, in a manner that remains unverifiable for both phenomenological and experimental methods). This contribution argues the opposite: the "self" informs our hypnagogic imagery precisely to the extent that we are not self-aware.

Klaus Conrad (1905-1961): delusional mood, psychosis, and beginning schizophrenia.

Klaus Conrad's major contribution to the phenomenology of psychosis focused on the patient's experiences during the prodromal and early psychotic phases of schizophrenia. The literature in English concerning his work is sparse, in part because Conrad's work contains complex concepts that lose much in translation. This communication attempts to clarify Conrad's thought, especially as it pertains to the role of mood and delusions in beginning psychosis and its underlying neurobiology.

Missing links in phenomenological clinical neuroscience: why we still are not there yet.

PURPOSE OF REVIEW: The phenomenology or systematic study of the patient's subjective experience in neuropsychiatric disorders is widely recognized as important. The methods used, the type of 'knowledge' obtained and the relationship of these observations to standard methods of clinical neuroscience, however, remain ill-defined and highly controversial. RECENT FINDINGS: Advances in the phenomenology of consciousness, self, body-experience, time-perception and intersubjectivity of neuropsychiatric disorders have been made. This review examines two differing approaches to the phenomenological psychiatry-neuroscience interface: the neo-phenomenological approach claims that some of its key concepts (e.g. the hyperreflexivity/ipseity model, prereflective self-awareness) are able to constrain neuroscience; the existential-phenomenological approach counters that phenomenology's role is not to constrain neuroscience but to provide hypotheses for further experimental study. This review compares these two approaches and assesses the current success of their respective claims. SUMMARY: By integrating work of largely untranslated authors, such as Binswanger, Blankenburg, and von Weizsaecker, neglected or cited out of context in the neo-phenomenological approach, the existential-phenomenological approach provides the 'missing links' between phenomenology and clinical neuroscience in a newly emerging but still fragile balance between disciplines. Optimistic claims about the ability of recently proposed phenomenological concepts (neo-phenomenological approach) to constrain neuroscience are unwarranted.

Perceptual anomalies in schizophrenia: integrating phenomenology and cognitive neuroscience.

From phenomenological and experimental perspectives, research in schizophrenia has emphasized deficits in "higher" cognitive functions, including attention, executive function, as well as memory. In contrast, general consensus has viewed dysfunctions in basic perceptual processes to be relatively unimportant in the explanation of more complex aspects of the disorder, including changes in self-experience and the development of symptoms such as delusions. We present evidence from phenomenology and cognitive neuroscience that changes in the perceptual field in schizophrenia may represent a core impairment. After introducing the phenomenological approach to perception (Husserl, the Gestalt School), we discuss the views of Paul Matussek, Klaus Conrad, Ludwig Binswanger, and Wolfgang Blankenburg on perception in schizophrenia. These 4 psychiatrists describe changes in perception and automatic processes that are related to the altered experience of self. The altered self-experience, in turn, may be responsible for the emergence of delusions. The phenomenological data are compatible with current research that conceptualizes dysfunctions in perceptual processing as a deficit in the ability to combine stimulus elements into coherent object representations. Relationships of deficits in perceptual organization to cognitive and social dysfunction as well as the possible neurobiological mechanisms are discussed.

Does negative symptom change relate to neurocognitive change in schizophrenia? Implications for targeted treatments.

Negative symptoms and cognitive dysfunction are among the most challenging obstacles in the treatment of schizophrenia. It is unknown to what extent they are overlapping or independent disease processes. In the search for targeted treatments of negative symptoms and cognitive impairments, it is imperative to determine their longitudinal relationship. 267 stable outpatients with schizophrenia in a work and cognitive rehabilitation program were evaluated using symptom measures and a comprehensive neuropsychological test battery at baseline and at the conclusion of rehabilitation, 6 months later. Baseline negative symptom, neuropsychological variables and change scores from intake to follow-up on these variables were correlated. These analyses were repeated with a subsample (n = 161) who had clinically significant negative symptoms at baseline. ANCOVA's were performed to compare patients whose negative symptoms improved by 5 points or more (n = 69) with those whose negative symptoms got worse by 5 points or more (n = 26) on their neurocognitive performance at follow-up. Intake negative symptoms were significantly associated with theory of mind and visuomotor processing. Results failed to support a lawful relationship between change in negative symptoms and neurocognition. These findings suggest that negative symptoms and neurocognition should be viewed as relatively independent targets for intervention.