Borderline We-Space? The Phenomenology of the Background of Safety in Borderline Personality Disorder.

Borderline personality disorder (BPD) is a severe psychiatric condition characterized by instability in identity, relationships, and affect. Individuals, with BPD typically lack a coherent sense of self, are highly sensitive to interpersonal stressors, experience intense fluctuations in mood, and frequently engage in impulsive and self-destructive behaviors. Although both empirical research and development of effective psychotherapy have evidently progressed over the past years, many aspects regarding the structure of experience and the life-world typical for persons with BPD are not yet fully understood. Somewhat surprisingly, phenomenological psychopathology has only recently started to pay more attention to the disorder. A comprehensive elaboration of the phenomenology of BPD is therefore still lacking. This article aimed to contribute to such a phenomenological understanding by focusing on what we think is an essential aspect that has yet not been sufficiently addressed: the background of safety. To clarify what this means, we depart from Sandler's [Int J Psychoan. 1960;41:352-6] psychoanalytic concept and elaborate on it phenomenologically. This leads us to argue that the development of a background of safety requires a particular embodied presence of others, which, in turn, contributes to the constitution of a safe we-space, a shared and familiar environment providing a matrix for the experience of a stable world. However, even when established, the background of safety remains in need of a continuous reconfirmation through corresponding experiences within a sufficiently reliable and controllable environment. The background of safety is vulnerable and open to (interpersonal) disruptions like trauma or neglect. In BPD, we suggest 3 aspects regarding the phenomenology of the background of the safety need to be considered: first, typically, patients with BPD did not develop a robust background of safety in infancy; second, weakening of the background of safety gives rise to symptoms and dynamics typical for BPD; third, these symptoms and dynamics further undermine the possible development of a background of safety in adult life and thus gravitate toward a petrification of the borderline condition, a "stable instability." To conclude, we examine whether this concept should be understood as a trouble générateur and, last, consider its clinical implications.

Uncovering the realities of delusional experience in schizophrenia: a qualitative phenomenological study in Belgium.

BACKGROUND: Delusions in schizophrenia are commonly approached as empirical false beliefs about everyday reality. Phenomenological accounts, by contrast, have suggested that delusions are more adequately understood as pertaining to a different kind of reality experience. How this alteration of reality experience should be characterised, which dimensions of experiential life are involved, and whether delusional reality might differ from standard reality in various ways is unclear and little is known about how patients with delusions value and relate to these experiential alterations. This study aimed to investigate the nature of delusional reality experience, and its subjective apprehension, in individuals with lived experience of delusions and a schizophrenia-spectrum diagnosis. METHODS: In this qualitative phenomenological study, we recruited individuals with lived experience of delusions and a schizophrenia-spectrum diagnosis from two psychiatric-hospital services in Belgium using homogenous sampling. Criteria for participation were having undergone at least one psychotic episode with occurring delusional symptoms, present at least 1 year before participation, on the basis of clinical notes assessed by the attending psychiatrist; a schizophrenia-spectrum diagnosis, ascertained through clinical interview by the attending psychiatrist upon admission; being aged between 18 years and 65 years; and having the capacity to give informed consent. Exclusion criteria included worries concerning capacity to consent and risk of distress caused by participation. We did phenomenologically driven semi-structured interviews with the participants to explore the nature of delusional reality experience and their subjective valuation of these experiences. We used interpretative phenomenological analysis, a qualitative method tailored to the in-depth exploration of participants' first-person perspective, to analyse their accounts. FINDINGS: Between March 2, 2020, and Sept 30, 2020, 18 adults (13 men and five women, aged 19-62 years) participated in the interview study. The findings suggest that delusions are often embedded in wide-ranging alterations of basic reality experience, involving quasi-ineffable atmospheric and ontological qualities that undermine participants' sense of the world as unambiguously real, fully present, and shared with others. We also found that delusional reality experience can differ from standard reality in various ways (ie, in a hypo-real and hyper-real form), across multiple dimensions (eg, meaningfulness, necessity and contingency, and detachment and engagement), and that participants are often implicitly or explicitly aware of the distinction between delusional and standard reality. Delusional experience can have an enduring value and meaning that is not fully captured by a strictly medical perspective. INTERPRETATION: Increased awareness and recognition of the distinctive nature of delusional reality experience, in both clinical and research settings, can improve diagnostic accuracy, explanatory models, and therapeutic support for individuals with delusions whose lived realities are not always evident from an everyday perspective. FUNDING: FWO Flanders. TRANSLATION: For the Dutch translation of the abstract see Supplementary Materials section.

The Impact of (the Concept of) Treatment-Resistant Depression: An Opinion Review.

Treatment-resistant depression refers to major depressive disorder, treatment of the disorder, and failure to obtain an "acceptable" outcome. Regarding the disorder, the heterogeneous concept of major depressive disorder and the multiple definitions of treatment-resistant depression, hesitating between a categorical and a more dimensional approach, as well as the divergence between diagnostic criteria and the items in the assessment scales are a source of confusion. Classifications do not take into account the dramatic influence of patient characteristics strongly impacting outcome, although these can be the cause of so-called pseudo-resistance. Outcome is the result of spontaneous evolution, nonspecific factors (including placebo), and active treatment factors. These should be differentiated to have a reliable estimation of the impact of different treatment modalities before we can asses treatment-resistant depression or before we can ascertain the (non)efficacy of treatments for treatment-resistant depression.The impact and burden of major depressive disorder and treatment-resistant depression are immense and go far beyond their economic cost. It is often forgotten that both are not only associated with increased suicidality but also with nonsuicidal mortality and that both can even result in requests for assisted dying. The caregiver burden and associated stigma are also too often overlooked despite that it has been suggested that they do influence (treatment) outcome.

Understanding the Blind Spots of Psychosis: A Wittgensteinian and First-Person Approach.

BACKGROUND: Experiences of psychosis are often assumed to be strange, bizarre, or incomprehensible. The aim of this article is to offer a new step towards a better understanding of how the psychotic process affects a prereflective background. METHODS: We use concepts from the philosophy of Ludwig Wittgenstein to clarify the first-person perspective on psychosis of one of the authors. RESULTS: We describe the early psychotic process as breaking down the "nest of propositions," shaking the scaffolds of our language games. Hereby, the prereflective background that forms our existential orientation in the world is fundamentally altered. We identify different aspects of this process: a dialectic of aha and anti-aha experiences, the experience of groundlessness, and blind spots. Acknowledging and exploring the depth and impact of this process on a person's world may be a first step towards resolving their isolation and suffering. Philosophy can facilitate such an exploration, while interpersonal activation may offer structure and trust in the world, helping the patient to find solid ground in action and interaction. CONCLUSION: This article combines a philosophical approach with a first-person perspective on psychosis to illuminate aspects of psychosis that have not been described or elaborated on before. We argue that psychosis entails an experience of existential groundlessness. Our view has implications for treatment of and recovery from psychosis.

Time and Events: On the Phenomenology of Temporal Experience in Schizophrenia (Ancillary Article to EAWE Domain 2).

Temporality and its disturbances have been a major topic of phenomenological psychopathology. Particularly Minkowski, Kimura, and Blankenburg described the temporal dimension of schizophrenia. After a brief introduction to their ideas, we describe more recent approaches to temporality in more depth. To this aim, we first distinguish between implicit and explicit time. Implicit time is based on the constitutive synthesis of inner time consciousness on the one hand, and on the conative-affective dynamics of life on the other. Explicit or conscious time experience arises with an interruption or negation of implicit time, and it unfolds itself in the dimensions of present, past, and future. Implicit time is based on a fluid and tacit bodily functioning and on affective synchronization with others, while explicit time arises through states of desynchronization, for example through retardation or acceleration of subjective time in relation to the social sphere. We clarify how a disturbance in temporality can lead to major symptoms of schizophrenia, such as thought disorders, hallucinations, or passivity experiences, and then consider the role of explicit temporal disturbances in schizophrenia.