Schizophrenia as a Disorder of Self, and Clinical Practice

Today's post is by Nimra Ahsan. Nimra is a fifth year medical student at the University of Birmingham, where she is currently completing a Masters in Mental Health. She is interested in how the study of mental health can help inform and improve future clinical practice, including her own. This is the last post in a series of perspectives from students taking the Philosophy and Ethics of Mental Health and Wellbeing module.

Nimra Ahsan

The interaction between psychiatry and psychopathology is one that is blending (Stanghellini and Broome, 2014). With a contemporary focus on patient experience, human subjectivity (or phenomenology) is creating a holistic perspective concerning mental health conditions, such as schizophrenia. Described as a ‘disturbance of minimal self’, our understanding of schizophrenia has deepened and the ipseity-disturbance model developed by Sass and Parnas has contributed to this substantially (Nelson, Parnas and Sass, 2014).

This model led to the formation of a symptom checklist, the Examination of Anomalous Self-Experience (EASE), which explores a patient’s ‘experiential or subjective anomalies’ in a semi-structured interview (Parnas et al, 2005). Built upon a Husserlian approach to phenomenology, this tool was established through descriptions from patients with schizophrenia spectrum disorders which collectively have an altered sense of self to help identify experiences of self-disturbance. However, it cannot be used alone diagnostically and does not yet include a comprehensive basis of anomalous experiences.

Regardless, research has shown that EASE not only demarcates schizophrenia from other disorders (Parnas and Henriksen, 2014), but could enable early recognition of self-disturbances and become a useful prognostic tool in those of clinical high risk (Værnes et al, 2021). Furthermore, in assessing basic self-disturbances, it was shown to aid detection of those at higher risk of non-remission or deterioration.

This study conducted by Værnes et al (2021) demonstrated that after one year of follow-up, increased levels of basic self-disturbances correlated with higher baseline levels (assessed using EASE) and were linked ‘with higher severity of positive, negative, disorganisation and general symptoms, and with a lower level of global functioning’. Additionally, a recent meta-analysis utilising EASE, concluded that self-disorders are specific to schizophrenia spectrum disorders, encouraging the idea that it should be considered a core clinical feature of schizophrenia (Burgin, Reniers and Humpston, 2022).

There have long been calls for diagnostic classification systems, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD), to revise their definitions and symptomology to include the patient’s subjective experience in order to curate a person-centred approach to diagnosis (Irarrázaval, 2015). The aforementioned developments in our understanding of schizophrenia further reinforce this notion; hence, these significant advances should be incorporated into clinical practice to help better treat those with schizophrenia. 

Understanding this disturbance of self and the way in which patients perceive the world can help clinicians to accept the conflict of realities between themselves and the patient. An emphasis should be placed on ‘recovery of the patient’s sense of unity with himself when rebuilding his capacity of doing and being’, allowing patients to lead fulfilling lives alongside their symptoms through repairing their sense of self (Irarrázaval, 2013). It is now incredibly important for clinicians to comprehend and apply this phenomenological approach to schizophrenia – in doing so, patients may gain a deeper understanding of their condition, empowering them, which in turn can ‘alleviate self-stigmatisation, diminish guardedness, and equip patients with better coping mechanisms’ (Humpston and Broome, 2020).

Psychotherapeutic approaches need to be developed based upon the ‘recognition of the self-disorders’ crucial importance in the patient’s life-world’, for example, through an emphasis on psychoeducation (Nordgaard, 2021). The use of psychopharmacology may aid management of symptoms, but approaches need to focus on empathetic understanding and open, effective communication between clinicians and patients, rather than correction of perception and thought (Wilson, Humpston and Nathan, 2021). Clearly, human subjectivity needs to be at the forefront of the management of schizophrenia.