<!-- image -->

Commentary                                                                                                                                             Open Access

## Self-disorders: A promising Candidate for Early Detection

Julie Nordgaard 1* & Mads Gram Henriksen 2,3

1 Psychiatric Research Unit, Region Zealand, University Hospital, Copenhagen, Denmark 2 Center for Subjectivity Research, University of Copenhagen, Denmark 3 Psychiatric Center Hvidovre, University Hospital, Copenhagen, Denmark

*Corresponding author: juef@regionsjaelland.dk

Early  intervention  for  patients  with  psychosis  has attracted  an  enormous  amount  of  attention  during recent decades. Research has shown that the duration of untreated psychosis has a significant effect on a patient's  long-term  prognosis  (1,2).  Findings  have also highlighted the importance of detecting individuals who are at high risk for the development of psychosis with the purpose of preventing the later transitioning  of  their  conditions  into  psychosis  or schizophrenia (3-6). The current approach that has been applied to detect these vulnerable individuals is the  clinical  high-risk  (CHR)  approach.  The  CHR approach includes the following: brief, limited, intermittent psychotic symptoms (BLIPS); attenuated  psychotic  symptoms  (APS);  genetic  risk and  functional  deterioration  (GRFD);  and  basic symptoms (BS).

However, reliable identification of individuals who are at high risk for the development of psychosis has proved  challenging.  A  recent  meta-analysis  of  the prognostic accuracy of the CHR approach emphasized the need to further improve its predictive value (8). In brief, the prognostic value of the CHR approach seems to depend on the examined sample.  For  example,  its  utility  for  a  non-helpseeking  sample  was  low,  but  it  was  excellent  for  a sample  of  help-seeking  individuals  who  had  been referred  to  specialized  services  (i.e.,  an  enriched sample) (8). In our view, part of the problem is that both BLIPS and APS include near-psychotic or brief psychotic features, so the samples tend to center on individuals in the late prodromal pre-psychotic phase. This renders the CHR approach vulnerable to being  criticized  for being  tautological: it is  not surprising that milder psychosis predicts more severe psychosis.  Furthermore,  the  meta-analysis  demonstrated  that  the  excellent  prognostic  value  of  the CHR approach was mainly mediated by its ability to rule out psychosis (as compared with its ability to rule in psychosis) (8).

A  novel and highly promising candidate for improving the early identification of individuals with mental states that have the propensity to unfold into schizotypal disorders or schizophrenia is the concept of self-disorders (SDs). SDs are non-psychotic experiential phenomena. During the last two decades, an accumulating amount of empirical studies  have  shown  that  SDs  constitute  a  specific experiential vulnerability phenotype of the schizophrenia  spectrum  (9,10).  The  idea  that  SDs form  core  features  of  schizophrenia  is  not  new; explicit  references  to  a  variety  of  abnormal  selfexperiences can be found  in nearly all of the foundational  texts  that  address  schizophrenia  (e.g., Kraepelin, Bleuler, Jaspers, Berze, Minkowski, Schneider).  It  is  important  to  note,  however,  that SDs affect the 'core' or 'minimal' experiential self (11-13). The idea of the core self refers to a first-person articulation of experience that is typically thought of as  ipseity,  selfhood,  or  'mineness,'  'myness,'  or 'for-me-ness' (14). It is a sense of self-presence and self-intimacy that implicitly or pre-reflectively permeates  an  individual's  consciousness  across  the flux  of  time  and  changing  experiential  modalities (e.g., perceiving, thinking, feeling). This sense of selfpresence may be described as a feeling of being a selfcoinciding subject of awareness and action. This selfpresence generally saturates our experiential life, and thus we never wonder if our thoughts, feelings, and bodily  movements  are  in  fact ours; the  question simply does  not arise.  Among  individuals  with schizophrenia spectrum  disorders, however,  this sense  of  self-presence  is  threatened  and  unstable, which allows a profound form of self-alienation to grow  from  within  the  disturbed  subjectivity  and result in a multiplicity of SDs. SDs include feelings of  being  ephemeral,  of  lacking  an  inner  core  or nucleus, of not feeling truly present or alive, of not being spontaneously immersed in the shared social world,  of  perplexity,  and  of  thought  pressure  or block (15).

Today, SDs are assessed with the Examination of Anomalous Self-Experience (EASE) scale (16). It is notable  that  certain  SDs  overlap  with  BSs;  see Appendix C of the EASE scale for details. However, the  definitions  of  the  overlapping  items  are  not completely identical. BSs are conceptualized as phenomena that first  emerge  during  the  stage  that occurs before the onset of manifest illness (17). By contrast, SDs are considered mainly trait phenomena that typically have been present for years before the onset  of  psychosis  and  that  tend  to  persist  during remission  after  a  frank  psychotic  episode.  From patients'  self-reports,  we  have  learned  that  SDs usually date back to childhood or early adolescence.

Follow-up studies of help-seeking, prodromal, and first-admission patients have shown that the presence of SDs predicts a subsequent schizophrenia spectrum  diagnosis  (18,19).  One  study  examined  a non-clinical population at high risk for schizophrenia and found that premorbid SDs significantly predicted lifetime schizophrenia spectrum diagnoses (20). Another study examined 87 help-seeking, nonpsychotic adolescents between 14 and 18 years for SDs and prodromal symptoms; 22% of the participants reported the presence of SDs at clinically meaningful levels. This study lends preliminary support to SDs as relevant and clinically useful tools that  can  be  used  to  supplement  and  refine  the methods of early  detection  (21).  In  our  view,  SDs offer great promise for the identification of some of the most vulnerable adolescents years before the full and often disabling crystallization of the schizophrenia syndrome. Screening for SDs in helpseeking  individuals  may  contribute  significantly  to improving the early detection, diagnosis, and treatment  of  our  younger  patients.  Therefore,  we suggest including examination of SDs with the use of the EASE scale as a part of the psychopathological assessment of adolescent patients.

## References

1. Hegelstad WT, Larsen TK, Auestad B, et al. Long-term follow-up of the TIPS early detection in psychosis study: effects on 10-year outcome. Am J Psychiatry 2012;169(4):374-80.
2. Penttila M, Jaaskelainen E, Hirvonen N, Isohanni M, Miettunen J. Duration of untreated psychosis as predictor of long-term outcome in schizophrenia: systematic review and meta-analysis. Br J Psychiatry: 2014;205(2):88-94.
3. O'Donoghue B, Lyne J, Madigan K, et al. Environmental factors and the age at onset in first episode psychosis. Schizophr Res 2015;168(1-2):106-12.
4. O'Donoghue B, Nelson B, Yuen HP, et al. Social environmental risk factors for transition to psychosis in an ultra-high risk population. Schizophr Res. 2015;161(2-3):150-5.
5. Schultze-Lutter F, Michel C, Schmidt SJ, et al. EPA guidance on the early detection  of clinical high  risk  states  of  psychoses.  Eur Psychiatry 2015;30(3):405-16.
6. Stilo SA, Di Forti M, Mondelli V, et al. Social disadvantage: cause or consequence of impending psychosis? Schizophr Bull 2013;39(6):1288-95.
7. Fusar-Poli P, Borgwardt S, Bechdolf A, et al. The psychosis highrisk state: a comprehensive state-of-the-art review. JAMA Psychiatry 2013;70(1):107-20.
8. Fusar-Poli P, Cappucciati M, Rutigliano G, et al. At risk or not at risk?  A  meta-analysis  of  the  prognostic  accuracy  of  psychometric interviews for psychosis prediction. World Psychiatry 2015;14(3):322-32.
9. Nordgaard J, Parnas J. Self-disorders and the schizophrenia spectrum: a study of 100 first hospital admissions. Schizophr Bull 2014;40(6):1300-7.
10. Parnas  J,  Henriksen  MG.  Disordered  self  in  the  schizophrenia spectrum: a clinical and research perspective. Harv Rev Psychiatry 2014;22(5):251-65.
11. Henriksen MG, Parnas J. Clinical manifestations of self-disorders and the gestalt of schizophrenia. Schizophr Bull 2012;38(4):657-60.
12. Parnas J. A disappearing heritage: the clinical core of schizophrenia. Schizophr Bull 2011;37(6):1121-30.
13. Skodlar B, Henriksen MG, Sass LA, Nelson B, Parnas J. Cognitivebehavioral  therapy  for  schizophrenia:  a  critical  evaluation  of  its theoretical framework from a clinical-phenomenological perspective. Psychopathology 2013;46(4):249-65.
14. Sass  LA,  Parnas  J.  Schizophrenia,  consciousness,  and  the  self. Schizophr Bull 2003;29(3):427-44.
15. Henriksen MG, Nordgaard J. Schizophrenia as a disorder of the self. J Psychopathol 2014;20:435-41.
16. Parnas  J,  Moller  P,  Kircher  T,  et  al.  EASE:  Examination  of Anomalous Self-Experience. Psychopathology 2005;38(5):236-58.
17. Gross G, Huber G, Klosterkötter J, Linz M. Bonner Skala Für die Beurteilung von Basissymptomen [Bonn scale for the assessment of basic symptoms manual]. Springer Verlag; 1987.
18. Nelson B, Thompson A, Yung AR. Basic self-disturbance predicts psychosis  onset  in  the  ultra  high  risk  for  psychosis  "prodromal" population. Schizophr Bull 2012;38(6):1277-87.
19. Parnas  J,  Raballo  A,  Handest  P,  Jansson  L,  Vollmer-Larsen  A, Saebye D. Self-experience in the early phases of schizophrenia: 5year follow-up of  the  Copenhagen  Prodromal  Study.  World Psychiatry 2011;10(3):200-4.
20. Parnas  J,  Carter  J,  Nordgaard  J.  Premorbid  self-disorders  and lifetime diagnosis in the schizophrenia spectrum: a prospective highrisk study. Early Interv Psychiatry 2014. doi: 10.1111/eip.12140
21. Koren D, Reznik N, Adres M, et al. Disturbances of basic self and prodromal symptoms among non-psychotic help-seeking adolescents. Psychol Med 2013;43(7):1365-76.