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Anomalies of subjective experience inschizophrenia and psychotic bipolar illness

Introduction

A recent series of editorials in major journals (14)has pointed to a dangerous decline of the science ofpsychopathology, especially affecting research inschizophrenia. In particular, studying the patientssubjectivity has become limited in scope and

methodology, because of unilateral concerns withreliability issues (5). An instructive example here isthe construal of the negative schizophrenic symp-toms as simple behavioural deficits a lack issignalled here by the deprivative a, e.g. a-logia,a-volition (6). Such account has transformed anentire range of phenomena, previously regarded asdiagnostic trait indicators of the schizophreniaspectrum disorders, into non-specific psychopath-ological features (2, 68). Most importantly, how-ever, this construal fails to vindicate the patientssubjective perspective, often populated by appar-

ently positive distortions of experience that resistcomprehension or description in pure deficit terms(6, 912).

This lack of psychopathological resources toaddress subjective experience is becoming striking-ly visible thanks to the recent, worldwide explosionof interest in early, prodromal detection of schizo-

phrenia (13). These therapeutically orientedprograms have inadvertently revealed that psycho-pathology is short of descriptions of subtle, not-yet-psychotic, anomalies of experience that mightbe accurately efficient in identifying individuals atrisk of imminent psychosis (14). Behaviourallydefined negative symptoms of schizophrenia are forthat purpose prohibitively common in the generalpopulation (7) and behavioural deviations alone,without exploring subjective experience, lack thespecificity necessary to predict future schizophre-nia (15, p. 962). In consequence, only intermittent

Parnas J, Handest P, Sbye D, Jansson L. Anomalies of subjectiveexperience in schizophrenia and psychotic bipolar illness.Acta Psychiatr Scand 2003: 108: 126133. Blackwell Munksgaard2003.

Objective: Contemporary psychopathology, as a result ofbehaviourally dominated epistemological stance, downplays anomaliesof the patients subjectivity. This neglect has probably deleteriousconsequences for research in the causes and the boundaries of theschizophrenia spectrum conditions. The purpose of this study is toexplore frequency of qualitative, not-yet-psychotic, anomalies of

subjective experience in patients with residual schizophrenia andpsychotic bipolar illness in remission.Method: The patients were examined with the Danish version of theBonn Scale for the Assessment of Basic Symptoms (BSABS).Anomalies of experience were condensed into rational scales with goodinternal consistencies.Results: Diagnosis of schizophrenia was associated with elevatedscores on the scales measuring perplexity (loss of immediate meaning),disorders of perception, disorders of self-awareness, and marginally so,disorders of cognition.Conclusion: These findings, in conjunction with those from other,methodologically similar studies, suggest that certain anomalies ofsubjective experience aggregate significantly in schizophrenia. These

experiential anomalies appear to be relevant for early differentialdiagnosis and therefore potentially useful in the preonset detectionof the schizophrenia spectrum illness.

J. Parnas1,2, P. Handest1,D. Sbye3, L. Jansson1

1Cognitive Research Unit, Copenhagen University

Department of Psychiatry, Hvidovre Hospital, Hvidovre,

Denmark, 2Danish National Research Foundation:

Center for Subjectivity Research, University of

Copenhagen, Copenhagen, Denmark, 3Institute of

Preventive Medicine, Copenhagen, Denmark

Key words: schizophrenia; bipolar illness; subjective

experience; self; basic symptoms

Josef Parnas, Danish National Research Foundation:

Center for Subjectivity Research, University of Copen-

hagen, Kbmagergade 46, 1150 Copenhagen K,

Denmark

E-mail: [email protected] or [email protected]

Accepted for publication February 4, 2003

Acta Psychiatr Scand 2003: 108: 126133Printed in UK. All rights reserved

Copyright Blackwell Munksgaard 2003

ACTA PSYCHIATRICASCANDINAVICAISSN 0001-690X

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or low intensity (attenuated) psychotic features arethe symptoms at hand for predicting a future full-blown psychosis in first-contact clinical popula-tions (14, see 16 and 17 as recent examples), apredicament, which despite its pragmatic useful-ness, is theoretically tautological.

Yet, non-trivial empirical evidence has in fact

been available for quite some time, demonstratingthat schizophrenia is frequently associated withcharacteristic non-psychotic qualitative anomaliesof subjective experience, which may antedateits onset. In the Anglophone psychiatry, it isMcGhie and Chapman (18) who are creditedwith the first systematic and very detailed descrip-tions of such experiences, replicated in few otherstudies (1921). Most recently these phenomenawere re-emphasized by a distinguished scholar ofschizophrenia, Paul Meehl, who proposed thatcertain alterations of subjective self-experience

deserve, from a diagnostic perspective, to

be listedalong with signs such as Bleulers associativeloosening (22, p. 190).

McGhie and Chapman identified, throughin-depth clinical interviews with first onset schizo-phrenic patients, subtle non-psychotic experientialanomalies in the domains of perception, cognitionand attention, body and movement awareness, aswell as alarming alterations in the domain of self-awareness, anomalies which usually predated theonset of psychotic symptoms. In the continentalEurope, an Austrian psychiatrist, Joseph Berze,collected rich clinical data demonstrating a variety

of subjective experiential anomalies occurring priorto, and at the onset of schizophrenia, which hegrouped into the categories nearly isomorphic withthose of McGhie and Chapman (23). Gerd Huber,Gisela Gross, Joachim Klosterko tter and theircolleagues in Germany pursued this research linefor several decades. In a series of long-terminvestigations of schizophrenic patients, they stud-ied qualitative experiential anomalies of the typealready addressed by Berze and McGhie. Theyconfirmed a status of these experiences as import-ant phenotypes of schizophrenia which usually

were present already in the preonset stages of thedisease. They coined these symptoms as the basicsymptoms, on a hypothetical assumption thatthese features were non-psychotic antecedents offull-blown psychosis and therefore causally prox-imate to the underlying biological dysfunctions(24, 25). These symptoms are defined in the BonnScale for the Assessment of Basic Symptoms(BSABS) (26), a comprehensive interview scheduletranslated into several languages, including Danish,and available in a preliminary English version fromits authors (27).

Aims of the study

The purpose of the present study was to assessspecificity of certain experiential anomalies, asmeasured by the BSABS, by comparing theirlifetime frequencies among the patients sufferingfrom residual schizophrenia and from psychotic

bipolar disorder in remission.

Material and methods

Patients

All patients were recruited from the psychiatricout-patient or day-patient facilities of the Cor-poration of Copenhagen University Hospitals, andwere required to suffer either from residual schi-zophrenia or a psychotic bipolar disorder inremission, according to the DSM-IV diagnostic

criteria (28). The referring clinicians were unawareof the exact study purpose. The diagnoses assignedby the treating clinical psychiatrists were verifiedwith respect to the operational criteria by aconsensus rating of two senior research psychia-trists using the OPCRIT symptom checklist (27).

The BSABS interview

The Danish BSABS version (26) was only pub-lished in 1995, after a laborious translation processwith a very close participation of its authors, andinvolving backward translations to both German

and English. Selected BSABS items, especially onperceptual and cognitive disorders (CDs) wereincluded in several of our schizophrenia studiesprior to 1995.

The BSABS is a semi-structured interview con-sisting of 98 principal items, most often dividedinto further subcategories, and described in aprototypical manner, i.e. briefly defined and illus-trated by examples of typical self-descriptions,supplemented by differential-diagnostic guidelines,question examples and suggestions of probes. Theinterview is divided into sections comprisingdynamic deficiencies

(e.g. anergia, anhedonia),anomalies of cognitive-perceptual and motor

experience, cenesthesias (CEN) (abnormal bodilyexperiences), and auto-protective efforts. Each itemis scored as absent, doubtfully present or definitelypresent. The time span covered by the interviewmay vary with the study purpose.

In the present study, the patients were inquiredabout the anomalies of experience on a lifetimebasis, i.e. the interview also focused on the experi-ences outside the symptomatic episodes. The aver-age interview duration was approximately 23 h.

Experience in schizophrenics and bipolars

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All interviews were conducted by one of us (PH), asenior psychiatrist with extensive research inter-view experience from a genetic linkage study, anda principal translator of the BSABS into Danish,and formally trained in Germany in its use byDr Klosterko tter, a co-author of the BSABS. Theinterviewer was blind to the DSM-IV diagnostic

status of the patient, but, naturally, he could notalways remain so during the course of the inter-view. The reliability of the BSABS is high (27) butits application requires both expert clinical experi-ence and extensive training. The kappa reliabilitycoefficients for single scale items used in the presentstudy were all above 0.60 (mean 0.72) betweenthe interviewer (PH) and a consensus rating by twoother clinicians (JP and LJ).

Data condensation and data analyses

The data were condensed into scales using arational clinical approach, motivated by our pre-vious research experience (3134) and our theoret-ical phenomenological orientation (35, 36). Theinterview items were grouped into seven a prioriscales (Table 1). Each scale was subjected to anitem analysis, which attempted to maximize coef-ficient alpha (37) by emphasizing biserial correla-tions between items and scale totals. This methodis related to other approaches to aggregating itemsinto scales, e.g. factor analysis but generally yieldssuperior results (38). Only one item from the totaloriginal item pool was removed because of alpha

degrading tendency. The intention behind thecomposition of the individual scales was to captureessential dimensions of the schizophrenia-spectrumpathology (35, 3941), i.e. 1) a general declinein the affective potential, 2) a subjectively experi-enced unease in the interpersonal/social contexts,3) perplexity (PY), i.e. a disturbed prereflectivearticulation or grip of meaning, 4) experience ofalterations in the processes of cognition, 5) anom-alies of self-awareness, 6) anomalous awareness ofthe body, and 7) perceptual distortions.

The interview items were originally coded as 0

(not present), 1 (doubtfully present) and 2 (defin-itely present); yet for the majority the patients onlyscores 0 or 2 were actually given. Hence the scoreof 1 was recoded into 0 (not present) and 2redefined as 1 (present) for all items. Two statisticalanalytic approaches were employed. First, conven-tional MannWhitney tests (the scales can beconsidered as being ordinal) were performed,with diagnosis as the independent variable andthe scale scores as the dependent variables. Sec-ondly, in order to obtain a clinically more usefulpicture of the discriminatory power of the scales,

a series of logistic regressions with odds ratiocalculations were conducted, with scale scores asindependent variables and the diagnostic status asthe dependent variable. The scale scores werehere dichotomized into comparably sized groups.The dichotomization of the scales allowed for a

Table 1. A priori scales with Cronbach's as and the BSABS-item numbers

Diminished affectivity (DA; a 0.69)

Diminished initiative and dynamism (A4)

Anhedonia (A 6.1)

Diminished feelings for others (A 6.3)

Diminished need for interpersonal relations (A 6.4)

Disturbed contact (DC; a 0.61)

Lack of ability for interpersonal contact (A 7.1)

Vulnerability to interpersonal contact (B 1.3.1)

Inability to tolerate crowd (B 1.3.2)

Increased impressionability by othersbehaviour (B 2.2)

Increased impressionability by otherssuffering (B 2.3)

Perplexity (PY; a 0.66)

Ambivalence (A 5)

Inability to discriminate between own feelings (A 6.2)

Hyperreflexivity/loss of naturaleness (B 3.1)

Disturbed receptive language (C 1.6)

Inability to re-visualize (C 1.14)

Inability to understand symbols (C 1.16)

Inability to grasp significance of perception (C 2.7)

Heightened perception (C 2.8)

Captivation of attention by perceptual detail (C 2.9)

Derealization: strangeness (C 2.11.1)

Derealization: intrusive perception (C 2.11.2)

Cognitive disorder (CD; a 0.63)

Thought interference (C 1.1)

Thought pressure (C 1.3)

Thought block (C 1.4.1)

Successive thought block and thought interference (C 1.4.4)

Disorder of expressive language (C 1.7)

Diminished thought initiative and goal-directedness of thinking (C 1.13)

Self-disorder (SD; a 0.65)

Psychic depersonalization (B 3.4)

Somatic depersonalization (D 1.1)

Mirror phenomenon, e.g. impression of a change in one's mirror image

(C 2.3.6)

Experience of discontinuity in own action (C 2.10)

Cenesthesias (CEN; a 0.55)Electrical bodily sensations (D 5)

Sensation of movement, pressure or pulling in the body or on the

body surface (D 7)

Sensations of lightness, heaviness, levitation, falling (D 8)

Sensations of constriction, dilatation, shrinking or expansion of the body (D 9)

Perceptual disorder (PD; a 0.63 )

Unclear seeing (C 2.1.1)

Partial sight (C 2.1.3)

Photopsia (C 2.2)

Micro-macropsia (C 2.3.2)

Meto-chromopsia (C 2.3.4)

Changes in perception of others faces or figures (C 2.3.5)

Skewed sight/disturbed perspective (C 2.3.8)

Disturbed sense of distance (C 2.3.9)

Disturbed rectilinearity (C 2.3.10)Dysmegalopsia (C 2.3.11)

Abnormal persistence of visual irritation (C 2.3.12)

Akoasm (hearing unformed noise, e.g. tinnitus) (C 2.4.2)

Changed intensity or quality of sound (C 2.5.1)

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calculation of P-values using the Fishers exacttest, which is desirable when the sample size is toosmall to rely on the asymptotic tests. Eight modelswere analyzed: seven univariate models, with eachscale entering into the model one at a time, and onemultivariate model testing all seven scales simulta-neously because the scales were intercorrelated:Pearsons mean r 0.37, range 0.100.59. Fur-thermore, 21 models, in which the scales wereentered two at a time, were analyzed, in order toexamine potential interactions between the scales.Two-tailed P-values < 0.05 were considered to be

statistically significant.

Results

The patients were all in the advanced illness stages(Table 2). There were no sex differences betweenthe groups, but the bipolar group was significantly

older than the schizophrenia sample (P < 0.01).No correlation was observed, however, betweenthe age and the scale scores within the diagnosticgroups or between the scale scores and the illnessduration. In the univariate with MannWhitneycomparisons of the scale scores as dependentvariables, schizophrenics and bipolars scoredequally on diminished affectivity (DA). On all theother scales the schizophrenia group tended toexhibit higher scores, and significantly so on fourof them (Table 3): PY, CD, self-disorder (SD), andperceptual disorder (PD).

The results of logistic regressions, with dicho-tomized scale scores as independent variables anddiagnostic status as the dependent variable appearin Table 4. In the univariate comparisons, schizo-phrenic diagnosis was predicted by high scores onPY, SD, and PD. Table 4 also shows the results ofa multivariate regression model, in which all scales

Table 4. Logistic regression analysis with status of schizophrenia as outcome and DA, DC, PY, CD, SD, CEN and PD as covariates

Covariate

Score

groups N. Sch. N. Bip.

Percentage

in score group

Odds Ratio

(95%-CI) univariate

Fisher's exact

P-value univariate

Odds Ratio

(95%-CI) multivariate

Type III P-value

multivariate

Diminished affectivity (DA) (four items) [0;3[ 7 10 38.6 1.00 (reference) 1.00 (reference)

[3;4] 14 13 61.4 1.54 (0.455.24) 0.489 1.07 (0.235.02) 0.931Disturbed contact (DC) (13 items) [0;2[ 7 14 47.7 1.00 (reference) 1.00 (reference)

[2;5] 14 9 52.3 3.11 (0.91-10.69) 0.066 1.59 (0.31-8.21) 0.580

Perplexity (PY) (11 items) [0;2] 9 17 40.9 1.00 (reference) 1.00 (reference)

]2;8] 12 6 59.1 3.78 (1.0613.45) 0.035 2.05 (0.3213.36) 0.449

Cognitive disorder (CD) (six items) [0;1] 9 14 52.3 1.00 (reference) 1.00 (reference)

]1;5] 12 9 47.7 2.07 (0.626.91) 0.231 0.78 (0.134.75) 0.787

Self-disorder (SD) (four items) [0;1[ 5 17 50.0 1.00 (reference) 1.00 (reference)

[1;4] 16 6 50.0 9.07 (2.3135.65) 0.0007 5.61 (1.2126.05) 0.024

Cenesthesias (CEN) (four items) [0] 9 14 52.3 1.00 (reference) 1.00 (reference)

]0;3] 12 9 47.7 2.07 (0.626.91) 0.231 0.84 (0.135.64) 0.856

Perceptual disorder (PD) (13 items) [0;1] 9 18 61.6 1.00 (reference) 1.00 (reference)

]1;7] 12 5 38.6 4 .80 (1.2917.88) 0.015 3. 02 ( 0.4819.17) 0. 237

Univariate: with only one scale at a time. Multivariate: adjusted for all seven scalesvariables at a time. Bold values are in significant Odds Ratios and corresponding P-values.

Table 2. Sample description

Number

of patients (males)

Age, mean

(SD)

Duration

of illness, years (SD)

Medication-life-time:

antipsychotics


lithium


antidepressants

Schizophrenia 21 (11) 33.9 (8.2) 9.4 (7.6) 21 3 7

Bipolar illness 23 (14) 45.5 (9.9) 15.1 (8.7) 22 19 21

Table 3. Scale scores as a function of diagnosis

Scale

Bipolar

mean (SD)

Schizophrenia

mean (SD)

P-values from

MannWhitney U-test

1 Diminished affectivity (DA) 2.75 (1.31) 2.65 (1.28) 0.8552 Disturbed contact (DC) 1.55 (1.49) 2.42 (1.43) 0.051

3 Perplexity (PY) 1.74 (1.05) 3.36 (2.35) 0.021

4 Cognitive disorder (CD) 1.00 (1.13) 2.01 (1.44) 0.026

5 Self-disorder (SD) 0.55 (0.94) 1.47 (1.17) 0.002

6 Coenesthesias (CEN) 0.39 (0.56) 1.03 (1.16) 0.069

7 Perceptual disorder (PD) 0.63 (0.79) 1.91 (1.87) 0.007


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were tested simultaneously. Only elevated score onSD was here predictive of schizophrenia diagnosis.A similar result emerged when only the scalessignificantly differentiating in the univariate com-parisons (PY, SD, and PD) were entered into themultivariate equation. None of the 21 interactionstested between two scales at a time reached the

probability level of 0.001, which was set as statis-tically significant because of the high number oftests.

Discussion

This study demonstrates that schizophrenia, whencompared with bipolar psychosis, is associatedwith increased levels of qualitatively anomaloussubjective experience, especially in the domain ofself-awareness, articulation of prereflective mean-ing, and perceptual experience. Other scales were

either entirely non-discriminating (sense of DA orCEN) or discriminated only at a nearly significantlevel (disturbed interpersonal contact). All patientswere in a stable, remitted condition, minimizingpotential effect of concurrent psychosis on the life-time measurements of experiential pathology.However, in view of the well-documentedmemory deficits in schizophrenia, a possibility ofdifferential recall between the diagnostic groupsmight have operated so as to attenuate thebetween-group differences.

Recent literature is replete with the studies usingself-rating questionnaires and reporting non-speci-

fic feelings of distress, e.g. lack of concentration,apathy, nervousness, irritability in various samplesof schizophrenia patients (4250). The scales usedin these studies do not target the qualitative orstructural alterations of subjective experience ofthe type examined here, and originally described byBerze, McGhie, Chapman and Huber, perhapswith the exception of certain scales assessingschizotypal dimensions (51) and the FrankfurtComplaint Questionnaire (52, 53), which measuresphenomena similar to those described in theBSABS. However, it is questionable, both on

methodological and empirical grounds, whetherself-rating instruments are ideally suited for asses-sing subtle changes in the qualitative structure ofsubjective experience (36, 5456).

To the best of our knowledge, there are onlyfour studies that are methodologically comparablewith the present study. Ebel et al. (57) employedthe BSABS in a comparison of 30 patients withremitted schizophrenia with 30 remitted melan-cholic patients. The schizophrenia group exhibitedmore qualitative experiential anomalies in theprocesses of perception and cognition. Cutting

and Dune (58) administered a self-developedinterview schedule to 20 remitted schizophreniapatients and 20 remitted depressed patients, andfound that schizophrenia was associated withqualitative anomalies of visual-perceptual experi-ences and, to a lesser extent, with qualitativelyaltered cognitive experiences. They concluded that

the processes of experience undergo a quantitativedecline in intensity or efficiency in affectivepatients and a qualitative alteration in schizo-phrenia (p. 228). Interestingly, the authorsobserved that the patients accounts of anomalousexperience were remarkably consistent acrossoccasions and interviewers. Klosterko tter et al.(59, 60) administered a shortened version of theBSABS to two samples of diagnostically heteroge-neous patients (n 489 and 243) and controls: inall comparisons, the schizophrenia group scoredhigher on each of the BSABS subscales than

substance-induced, neurotic and personality disor-ders and normal controls. In addition, schizophre-nic patients scored higher than depressed patientson the scales targeting cognitive-PDs and CEN.

Our study extends the findings quoted above,suggesting that certain qualitative experientialalterations are not simply markers of psychosis ingeneral, but aggregate selectively in schizophrenia.We have reported elsewhere that the BSABS-defined anomalous cognitive and perceptualexperiences also occur in schizotypal individualsidentified in a genetic family study (61).

The issue of prodromal specificity of the BSABS-

defined anomalies of subjective experience wasrecently addressed by Klosterko tter et al. (27) in aprospective 10-year follow-up study of non-psy-chotic psychiatric patients. The initial presence ofthe cognitive-perceptual basic symptoms washighly predictive of a subsequent development ofschizophrenia, correctly predicting the outcome in78% of the sample (27) (Table 5).

The joint evidence from this and the methodo-logically similar studies quoted above, indicatesthat schizophrenia is differentially associated withqualitative aberrations in several modalities of

conscious experience, aberrations that may turnout as useful for early differential diagnosis andhence assist in the prediction of future schizophre-nia among non-psychotic psychiatric patients.

Of particular interest here is our finding of thediscriminating value of the anomalies in self-awareness [albeit it must be pointed out that theBSABS measures are rather crude with respect tothe potential range of manifestations of SDs(32, 38)]. In two retrospective phenomenologicallyguided studies of first-onset schizophrenia spec-trum patients (n 20 and 19, respectively),

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qualitative alterations in self-awareness were foundto be the dominating experiential aspect of thepreonset phases (62, 63). We have replicated thisfinding quite recently on a larger sample (n 155)of diagnostically mixed first admitted patients: dis-orders of self-experience discriminated very stronglybetween the schizophrenia spectrum patients and

the patients with various non-spectrum diagnoses(35). Thus, alterations of the sense of self mayperhaps point to a core phenomenological featureof schizophrenia, with important implicationsfor diagnostic boundaries and pathogenesis(8, 41, 64, 66).

In conclusion, certain qualitative alterations ofsubjective experience seem to antedate the emer-gence of psychotic symptoms in schizophrenia andit appears that this evolution may follow charac-teristic, i.e. non-random, phenomenal patterns(25, 64, 66).

The disorders of subjective experience have beenproposed, mainly on the basis of their factorialstructure, to constitute an independent symptomdimension in schizophrenia (45). However, factor-ial structures are notoriously sensitive to thesamples from which they derive and their illnessstages (67) and are moreover strongly influenced bythe composition of the items and the instrumentsused in the first place to elicit these items {the so-called methodological factors [see (68) for a recentassessment of factor analysis in psychometricresearch]}. It is therefore likely that observedbehaviours and expressive features on one hand

third-person data, and the information obtainedfrom subjective reports on the other hand first-person data, may mathematically gravitate intoseparate dimensions, without implying a real splitbetween experience and expression or a homogen-eity of subjective experience.

Acknowledgments

This study was supported by a grant from University of

Copenhagen (Dr Handest), a grant from the Corporation of

Copenhagen University Hospitals (Dr Parnas) and a grant

from the Danish National Research Foundation (Dr Parnas).

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