Original Paper Received: December 7, 2012 Accepted after revision: December 5, 2013 Published online: January 24, 2014
Psychopathology DOI: 10.1159/000357759
The Phenomenology of Emotion Experience in First-Episode Psychosis V.V. Vodušek a J. Parnas b M. Tomori a B. Škodlar a a
University Psychiatric Hospital Ljubljana, Ljubljana, Slovenia; b Center for Subjectivity Research, Copenhagen, Denmark
Abstract Background: Although it has been suggested that disturbances in emotion experience and regulation play a central role in the aetiology and psychopathology of schizophrenia spectrum disorders, the phenomenology of emotion experience in schizophrenia remains under-researched. Sampling and Methods: In-depth interviews were conducted twice with each of the 20 participants (firstly at admission and secondly 6 months later). Data collection and analysis were guided by the principles of phenomenological study of lived experience. Results: The emotion experiences described by our participants vary greatly in both quality and intensity, but appear to have a common phenomenology. Anxiety is reported as the basic emotion which buffers, transforms and sometimes supplants all others. Emotions in general are experienced as foreign, unstable and perturbing, thereby contributing greatly to feelings of ambivalence, perplexity and an unstable sense of self in general. Conclusions: The findings of this study have important therapeutic and theoretical implications because they suggest that emotion experiences in schizophrenia spectrum disorders may underlie a wide range of psychopathological phenomena in both the cogni-
© 2014 S. Karger AG, Basel 0254–4962/14/0000–0000$39.50/0 E-Mail [email protected] www.karger.com/psp
tive and social functioning domains. Due to the relatively small sample size and its selection from psychotherapeutic units, the results may not be generalizable to all schizophrenia patients. © 2014 S. Karger AG, Basel
Introduction
The Phenomenology of Schizophrenia Spectrum Disorders and the Phenomenology of Emotion Experience Picking up the legacy of mid-20th-century European phenomenological psychiatry [1], contemporary phenomenological psychopathology conceives the core of schizophrenia spectrum disorders (SSD) to inhere in a specific alteration of the structure of conscious experience (the ipseity disturbance model [2, 3]). The basic structure of subjectivity (consciousness), underpinning all reflection and self-world interactions is ipseity: all experience is given to me as my experience, i.e. it displays a basic character of first-personal givenness, ‘mine-ness’ or ‘for-me-ness’ [3]. The ipseity disturbance model proposes that SSD in their various presentations are characterized by an instability of this basic experiential structure. The ipseity disturbance involves an interplay of diminished self-affection and hyper-reflexivity [3]. Diminished self-affection V.V. Vodušek University Psychiatric Hospital Ljubljana Studenec 48 SI–1260 Ljubljana (Slovenia) E-Mail vvvodusek @ gmail.com
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Key Words Phenomenology · Emotion · Subjective experience · Psychosis · Schizophrenia spectrum disorders · Ipseity disturbance
EmEx in SSD Although it has been proposed that disturbances in EmEx are a core feature of paranoid schizophrenia [11] and SSD in general [12], the phenomenology of EmEx in SSD remains under-researched. Aiming to bridge the paradox of simultaneous emotional hypo- and hyper-sensitivity observed in (predominantly negative) SSD [13–15], Sass [16, 17] conceptualizes EmEx disturbance in terms of 2
Psychopathology DOI: 10.1159/000357759
‘non-emotional affectivity’ (emotionality proper is diminished while other – non-emotional – forms of affective response are preserved or even heightened). Quantitative studies show that emotional expression is diminished in SSD, but in the areas of recognition and experience of emotions the results are widely inconclusive: the only robust finding is that people with SSD tend to have a negative bias in both areas (compared to controls, they experience more negative emotions and are more prone to perceiving emotional stimuli as negative) [18, 19]. More consistent findings have been reported: (1) on the disorganizing effect of (especially negative) affect-laden topics on speech production [20] and (2) on the disturbance of autobiographical [21] and emotional [22] memory in SSD. When conversing on or recalling topics that elicit EmEx, the specificity and coherence of the narrative produced in SSD is markedly impaired. Alexithymia [23] and reduced emotional awareness [24] have also been shown to be a trait characteristic in SSD. The above findings imply a negative bias in and a disturbed grip on EmEx in SSD: patients experience more negative and disturbing emotions than controls, and they are less able to discriminate between different emotions, both of which seems to contribute to a disorganizing effect of EmEx on cognition. Anxiety and Social Anxiety in SSD and Their Impact on Social Cognition and Metacognition From among the various emotional/affect states in SSD, anxiety is the only one that has been extensively researched and is even considered by some to be the core symptom of SSD [25, 26]. A recent meta-analytic study has estimated the prevalence of different anxiety disorders in SSD at 10–20% [27], with some studies reporting elevated levels of social anxiety in first-episode psychosis in up to 60% of participants [28, 29]. Social anxiety in SSD is associated with greater deficits in mentalizing and social cognition in general [30], worse performance on metacognitive tasks [31] and, consequently, greater disability in social functioning [28, 30, 32] and poorer quality of life [33]. Methods Data collection and analysis were guided by two main principles of phenomenological study of lived experience: (1) exclusive and detailed focus on the subjective experience as described and interpreted by participants and (2) suspension of theoretical pre-
Vodušek /Parnas /Tomori /Škodlar
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may manifest itself as a lack of a vital support from the lived body and a sense of disconnectedness from the world: feelings of disembodiment [4], sense of ephemeral existence, and overall alienation from one’s own subjectivity. The world appears as if lacking affordances [5] (meaning), the subject feels not real and lacking action potential. The ‘mine-ness’ quality of subjective experience is manifested in what we can call the ‘Janus-face’ [6] of emotion experience (EmEx): the world appears to me in a certain way by dint of the emotional state I find myself in (and vice versa). The phenomenological manifestation of EmEx always involves a certain evaluative component and a felt action attitude [7]: I don’t become angry because somebody is perceived as offensive, and I don’t feel the tendency to retaliate because I am angry. The perception of somebody as offensive and the felt tendency to retaliate is exactly what constitutes anger. It is the totality of a given EmEx which constitutes and presents a given self-world relation for the subject; in immersed states of EmEx the perceptual and conceptual field can be completely transformed, which Sartre called the ‘magical’ property of emotions [8]. EmEx vary greatly in intensity and duration, detachment versus immersion and the general directedness of attention toward the self, others or the world, articulated as a figure-ground gestalt [7]: in immersed states one cannot experience the world and the self simultaneously, as one always displaces the other. The pre-reflective phenomenology of anger is experienced either as ‘self-as-offended’ or as ‘bastard-deserving-of-retaliation’. It is only in the more detached and analytic mode of reflective consciousness that one can bring focal attention to bear selectively on one or the other aspect of a given EmEx figure-ground articulation. If the lived body [9] is a set of innumerable potentialities that can be realized through the world’s affordances, it is EmEx that place the self in specific impelling relations to the world. The world appears as meaningful in this or that respect by its emotional salience and the responses called for [10].
Age, years
Gender (male)
Schooling, years
Untreated psychosis, months
22.1 ± 4.9
60%
13.6 ± 3.2
10.9 ± 6.4
Values are presented as means ± SD.
suppositions on the subject matter (epoché) in the investigative effort of the researcher [34]. Sample The sample consists of 20 first-episode (non-affective) psychosis patients consecutively admitted to the Unit for the Psychotherapy of Psychoses and the Unit for Adolescent Psychiatry in the Centre for Mental Health of the University Psychiatric Clinic Ljubljana, who were diagnosed by a senior clinician (B.Š.) on the basis of a Present State Examination clinical interview [35]. The following were excluded: (1) patients abusing psychoactive substances and (2) those with a known psychosis-inductive organic disorder. All patients were sufficiently organized in speech and thought (i.e. in the main, past the acutely psychotic phase) to be able to participate in the intensive psychotherapeutic programme. All participants signed statements of informed consent. The study was approved by the national bioethics committee. Table 1 shows the age, gender, years of schooling, and duration of untreated psychosis of the participants. Procedure In-depth interviews were conducted in an open-ended and loosely structured manner that allowed for: (1) spontaneous unfolding of the participants’ narratives and (2) gradual crystallization of the basic experiential elements through hermeneutic dialogue [36]. A given interview lasted from 1 to 4 h depending on: (1) the quantity of elicited material and (2) the participant’s appreciation of the hermeneutic dialogue, i.e. the degree to which additional probing yielded new aspects to the experiential gestalt at hand. A single interview session never lasted more than 1 h, which means that longer interviews were conducted over several sessions. The two main foci of the interviews were: (1) the quality of EmEx as they arise in the everyday life of the participant and (2) the relation of these EmEx to the basic sense of self of the participant. The interviewer did not operate with a pre-defined set of questions but tried to access EmEx indirectly via exploration of personal narratives. The participants were neutrally encouraged to talk about their everyday experiences, and the interview then gradually focusing on the EmEx that were involved in a given narrative fragment. As ipseity disturbance is not delimited to schizophrenia alone but underlies a specific way of being-in-the-world for the whole spectrum [37, 38], the participants were asked to describe their EmEx before, during and after psychosis. Regarding the pre-psychotic EmEx, the participants were asked to describe their most
Emotion Experience in Psychosis
self-defining emotional memories with no time interval constraints. As it has been shown that pre-psychotic personal narratives are usually engulfed by psychosis and its aftermath [39, 40] and so cannot be comprehensively accessed at the time directly following decompensation, the interviews were conducted twice with each participant: firstly at admission and secondly 6 months later. All interviews were transcribed verbatim and analysed by the first author, the analysis being guided by the principles of phenomenological hermeneutics [41]: following several re-readings to obtain a grip on the overall organization of the experiential field at hand, the main themes were identified and coded; then common experiential denominators of these themes were extracted and lastly a synthesis was attempted for phase-specific EmEx gestalts and their relation to the sense of self. For purposes of reliability, the last author analysed eight randomly selected interviews de novo, then the results of both analyses were compared and scrutinized. As inter-subjective consensus regarding the selected interviews was high, the remainder of the interviews were discussed on the basis of the first author’s verbal report. An agreement was reached concerning relevant interpretive incongruences, so that the final results represent a consensus between the two authors.
Results
The main findings of the study will be presented in the order of relevance and salience as experienced and reported by the participants, but firstly we must acknowledge the development of themes across the two interviews: the pre-psychotic way of being-in-the-world seemed experientially distant and ‘in another world’ for the participants in the first round of interviews. They could describe the crude outlines of their familial, social and academic- or work-related functioning, but seemed hard-pressed when asked about more specific EmEx. They seemed partially aware of the oddness of this predicament, but explained it off as ‘poor memory’ and assured the interviewer that their past was nothing like what they were experiencing now. The participants, who were interviewed over several sessions in the first round, regained some contact with their past, but only in experiential fragments, so that a more comprehensive gestalt of EmEx in question emerged only by the second round of interviews. Emotional Emptiness and the Sense of Loss and of Being Lost in the Post-Psychotic Self EmEx in the post-psychotic phase were generally described in terms of loss and of being lost. The vast majority of participants described loss of emotions leading to diminished vitality and motivation. Intimate relationPsychopathology DOI: 10.1159/000357759
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Table 1. Sample characteristics
‘I used to be more emotional than I am now. In relation to the problems of other people for example: I haven’t been feeling any sympathy lately. Even if I see something really bad on TV, something that would have made me want to weep in the past, it doesn’t affect me at all now. It’s as though I am empty inside.’
This emotional emptiness is not experienced as a void but rather as a present absence: although most participants affirm that they feel ‘nothing’, this is always experienced as a missing out of ‘something’ that they used to feel, or rather something that they ought to feel. It is never a lack of feeling per se, but merely a lack of distinctive EmEx: there is always a feeling present, but it is hard for the participants to communicate it, because it does not take a definite form. It is described alternatively as tension, pressure, vulnerability or a fear of everything. None of the participants originally used the term ‘anxiety’, but most of them welcomed it as an apt description. This presence of anxiety appears as a flip side to emotional emptiness and is experienced as a constant background of everyday life in the post-psychotic phase. All but 5 of the participants experience an amplification of this basic anxiety in situations that used to elicit more definite EmEx in the past. ‘I used to like driving my car, living in my own apartment, talking with friends, but now I feel as though I have to start from scratch and learn everything anew: I am afraid to drive, afraid to stay alone in my apartment, afraid to accept an invitation for a drink with a friend. I have to force myself to try these things as though I had never done them before.’
Distinctive EmEx which normally provide orientation and motivation are dissolved into an amorphous and unnerving sense of overwhelming anxiety that renders the subject lost and immobile; this state was aptly described by one of the participants as ‘frozen between fight and flight’. Emotional emptiness is alternatively described as a ‘loss of contact’ both with the world and its affordances and with the self and its potentials: by dint of the world failing to transpire as something to be happy, sad or angry about, the sense of self also remains opaque. All but 3 of the participants describe a pervasive sense of insecurity about themselves most commonly called ‘bad self-image’. They don’t feel less worthy than other people, however, but lack a stable reference frame of self-to-world altogether. In the same way as they feel estranged in (social) interactions for lack of (interpersonal) emotional attunement, 4
Psychopathology DOI: 10.1159/000357759
they also feel perplexed about themselves as (social) beings: they don’t know whether they are amusing or boring, able or unable, welcome or unwelcome. This loss of contact with the self and the world makes for an overall sense of being lost. ‘I don’t know what to say and how to respond when I’m with friends. They laugh at my jokes but I can never tell if they’re not just being nice and pretending to be amused ... I don’t know what I’m good at or even what I want to do in my life: I often wonder whether there even is a job for my profile ...’
This sense of being lost is accompanied by overwhelming feelings of hopelessness, which are usually described as ‘depression’ as they often entail suicidal ideation. When more closely examined, however, participants never describe feeling sadness as sadness, but rather as an amplification of the basic anxiety that they wish would be sadness, so they could release themselves of it by mourning and weeping. ‘I am never really sad, because I am emotionally numb. I feel a certain sadness almost all the time though – I’m sad because of this numbness. I often wish I could weep, feel this sadness fully, but I can’t ... there is always just this feeling of numbing tension.’
Emotional Buffer, Lack of Flow and Mourning for Authenticity in the Pre-Psychotic Self The overarching theme of the pre-psychotic way of being-in-the-world is that of an emotional buffer in relation to the self, world and others. The participants described this emotional buffer alternatively as a ‘bubble’ surrounding them, a ‘curtain’ in the way of EmEx, or a state of being ‘comfortably numb’. The emotional buffer was reported as present from the very start of puberty (from around 12–14 years of age). The emotional buffer does not imply a simple subtraction of EmEx intensity and/or duration, but rather diminished immersion. Most of the participants usually recognized the emotion that a given self/world evaluation and felt action tendency implied, but rarely ever felt that they were present in and in contact with the experience. EmEx is ‘detected’, but not inhabited: it skims the periphery of consciousness as a wave going by – a wave they wish to ride and be one with, but can’t. As with emotional emptiness, the emotional buffer effects itself as a presence, again most aptly described as anxiety. ‘This sense of numbness is always present to some extent – it is a tension and a scatteredness of attention in everything I do and everyone I meet ... like I wasn’t fully connected, like there is a buffer.’
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ships no longer elicited feelings of warmth and comradeship, jokes that made them laugh or movies that made them weep no longer stirred discernible emotions in them.
Buffered through anxiety, joy isn’t experienced as inhabited joy, but as a sense of crude euphoria that is somehow foreign to and forced upon the subject. This implies a potential for negative interaction between anxiety (that buffers EmEx in the first place) and EmEx: the advent of a given EmEx (estranged by the buffer) exacerbates both the initial anxiety and the potential for immersion, inciting the subject to ‘get it over with’, ‘do something about it’, i.e. withdraw from EmEx altogether. EmEx are highly ambivalent as they are experienced both as a missing out, as something that should be there but isn’t, and as a perturbation, as something to be gotten over and done with. The participants describe a lack of ‘calm’ and ‘immersion’ in their EmEx, which constitutes lack of contact with oneself and one’s environment, or as one participant put it: not being ‘in the flow’. This feeling of deficit can compel the subject to attempt to ‘amplify’ the EmEx called for in a given interpersonal situation by conscious effort, which further exacerbates the sense of ‘not-being-oneself’ and may incite fear of being declared a ‘fake’. ‘I feel the emotions but in a very attenuated way. Sometimes I have the feeling that I have to amplify a certain emotion; I try to hold on to it, grab it before it gets away. I think others are more spontaneous in this, it comes to them more freely and stronger. Because others aren’t familiar with this (particular quality of EmEx), they might think that I’m just faking it, that I don’t really have the emotions I show.’
The emotional buffer makes for an overall sense of lack of authenticity and realness of self, which contributes to a general mood reflecting the ambivalence of particular EmEx: most of the participants describe an ever-present combination of burdening numbness and estrangement on one side and an undifferentiated sadness and mourning for the perceived lack of contact on the other. ‘I’m not in contact, I don’t feel present as a person, don’t have a sensation of myself. I feel like a ghost – in the sense that I am not inside (myself). I am here physically but not psychically... I tried to weep, but I just can’t. It just doesn’t connect: it’s just like ‘ǝǝǝǝǝ’ (= a muffled sound), like there was a pillow in between ... I often tried weeping, just for being in this state, just to get out of it.’
Emotion Experience in Psychosis
This seems like a paradox: there is both a sense of diminishment of ‘presence in’ or ‘contact with’ sadness, and mourning for this very diminishment. It seems as though the sense of a diminished capacity for mourning serves as the basis for mourning itself. Full Contact, Emotional Overwhelming and Fear of Annihilation in the Psychotic Self Contrary to the sense of buffered presence or loss of presence characteristic of the pre- and post-psychotic person, the advent of psychosis is experienced by the vast majority of participants as an internal release of tension, a lifting of the ‘curtain’, a rebirth of the authentic subject that is only now allowed full contact with the self. ‘It felt as if a certain tension in the back of my brain was released, as if something collapsed back there, that was creating tension ... it seemed as if I was born anew.’ ‘It was a very powerful experience: I came in full contact with emotions that were suppressed in a distant past. It was as if certain channels opened that had been closed and dusty for a long time; like I was in contact with my true self again.’
This ‘coming into contact’ entailed various delusional and hallucinatory experiences that we shall not expound on, as this has been dealt with extensively in the phenomenological account [42, 43]. What is crucial here is that the advent of psychosis is experienced in more than half of the participants as being at one with oneself (sorely lacking in the pre- and post-psychotic self), positive emotional immersion of an undifferentiated sort and an absence of numbing sadness. ‘In the beginning I was feeling good and full of hope, at times ecstatic. I had the feeling that if I tried hard enough, I could change into a better person, and help make the world a better place.’
This feeling of ‘full contact’ is accompanied by a sense of being in control and a strong feeling of will and a certainty that change is possible: a change of the self and/or a change in the world. As time passes, however, this experiential field is turned outside-in, and the subject feels haunted by the very world he seemed to control, great fear of punishment or annihilation overwhelms him, and as all sense of temporality is lost, so also change becomes merely an article of faith – of hope against hope. If they never felt quite at home in the world that had presented itself through a veil of anxiety in the pre-psychotic phase, in the catastrophic phase of psychosis the world seems completely changed, foreign and threatening. ‘I didn’t recognize the environment anymore, like I couldn’t orient myself, it all seemed foreign – this made the fear even worse. When I went to the police station, I didn’t know whether they were
Psychopathology DOI: 10.1159/000357759
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‘When I come home, I never feel a certain warmth, a sense of safety. I always feel, not exactly in danger, but not relaxed or at home with myself and others. When a friend comes by joyful about something and wanting to do something, I mean I am also joyful about it although I don’t really know joy ... with me it’s more like a euphoria: it comes just like that, from nowhere ... so I would go ‘Yeah, let’s do it!’, but just to do something about it, to change something; there is never calm in my emotions.’
The interesting thing is that although all participants recognized the psychotic episode as an experiential anomaly, most of them nevertheless resisted reducing it to a neurochemical abnormality or a disease in the sense of something foreign that needs to be eliminated. Although their psychosis also entailed great suffering, all but 6 of the participants still seemed to find an important personal value in the overall experience: as though the sense of flow and hope they experienced in initial psychosis served as a sort of private proof that they are capable of full contact and authenticity. They remained ambivalent about this contact, however, both because of the phantasmagoric landscape it led into and because of the gradual recognition that this contact was also in a way false, because it did not involve real persons, real actions and, consequently, real emotions. ‘It all seemed very real, the different energies that I wanted to get in touch with. But at the same time I never really felt that I was truly in contact with them. It all remained somehow superficial and metaphysical, as if on another energy level – it lacked human warmth.’
It seems that the buffered quality of EmEx did not altogether disappear in the psychotic break, but rather that the intensity of EmEx amplified to such a degree that they substantially overshadowed the buffer’s effect.
Discussion
We wish to emphasize that the recruitment from psychotherapeutically oriented units might have resulted in a biased sample in terms of lesser comorbidity and lower severity. However, such trade-off was necessary and does not pre-empt our main goal of mapping emotional experiences in SDD. Using the narrative approach, we are, by definition, limited to participants’ reports and interpretations of experiences that are accessible to memory and reflection. All our inferences about the nature of EmEx – especially those pertaining to EmEx long past, i.e. from the pre-psychotic phase – must therefore be qualified to a certain extent, as we cannot be sure to what degree they reflect disturbances of (autobiographic) memory [21, 22]. It must also be noted that the inferences presented here necessarily reflect the theoretical and professional back6
Psychopathology DOI: 10.1159/000357759
ground of the authors – others may well have reached different conclusions from the same material. We believe, however, that we have minimized both potential sources of error by limiting ourselves as closely as possible to what is common to most of the experiences described by the participants (which also means that we have sought to highlight what is common to both past and recent memories/experiences). Our analysis of EmEx in SSD is in line with the two general findings in the literature: (1) there is a prevalence of negative EmEx (especially anxiety and undifferentiated sadness) in both the pre- and post-psychotic self [18, 19] and (2) EmEx in general are both subjectively unstable and hard to access [21–24] and have a disorganizing effect on reflective processes [20]. Consistent with other studies [27–29], anxiety appears to be the most prevalent and basic EmEx in SSD: it is not tied to any one concrete situation but pervades, transforms, and sometimes supplants, all other EmEx. It has no one definite object but rather entails a drawing away from all things (including oneself), making for an overall feeling of uncanniness or ‘not-at-homeness’: following the analysis of angst of Heidegger [44], Ratcliffe [45] describes this kind of EmEx as existential feelings (an everpresent backdrop to experience and thought that affects both but has itself no concrete object or intention), which are prominent in psychiatric disorders, typically in SSD. Anxiety in our sample persists in spite of or is exacerbated by distinct emotions, which forms the essence of what we call emotional buffer and emotional emptiness. There seems to be both a dissociation and a negative interaction between anxiety and other EmEx that appears to be specific to SSD emotionality: anxiety subjectively estranges other EmEx and is itself amplified by the EmEx thusly transformed. These disturbances of EmEx led our subjects to feel disembodied, perplexed and pervasively ambivalent. From the very beginnings of descriptive psychopathology of schizophrenia, ambivalence [46], perplexity [47] and disembodiment [4] feature as core dimensions. These anomalies of EmEx, present in the everyday lives of our patients before and after the psychotic episode, closely parallel the findings of contemporary phenomenological research of basic self-world disturbances in SSD, i.e. anxiety, estrangement and exposure [48]. Our analysis suggests that the EmEx described by our participants have a common phenomenology: joy is experienced as crude euphoria, sadness as undifferentiated burdening numbness, etc. Under the label ‘emotions’ participants describe a disturbing numbness with variable Vodušek /Parnas /Tomori /Škodlar
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the actual police or whether they were somehow connected with the story (= delusion). When I went to meet my mother in the airport, I wasn’t sure whether it was the XY airport or whether I was somewhere else ...’
our subjects and further destabilizes their sense of basic self: this leads our subjects to different adaptation mechanisms similar to the ones described in the literature as ‘false self systems’ [53] and ‘positive withdrawal’ [54]. The perceived lack of contact with the authentic self, described in the literature as ‘false’ [55] and ‘emptied’ [56] self, is intrinsically related to a pervasive sense of loss, leading to feelings of bare and numbing sadness in our subjects: it would appear that besides anxiety, undifferentiated sadness also features as an existential feeling [45] in SSD, which parallels the conceptualization of psychosis as complicated mourning, as described by Wittmann and Keshavan [57] (in our case, the feeling of ‘being authentic’ is described mainly in terms of contraposition to the emotional buffer: ‘being authentic’ therefore does not imply any definite kind or set of EmEx but a certain qualitative change of EmEx in general, i.e. them being more selfpresent, experienced more directly and close-to-self). The undifferentiated sadness described by our participants seems to have a different phenomenology than depression and is more akin to SSD-specific ‘disembodiment’ than to ‘corporealized melancholia’ [4]. However, we cannot reliably dissociate this undifferentiated sadness from post-psychotic depression [58] in the context of demoralization and stigmatization [59, 60] on the basis of our analysis alone. The emotional buffer and/or emptiness described in this paper are not only a source of pain in themselves, but also present a great obstacle in the achievement of intersubjectivity: subjective uncertainty in the EmEx of own self is closely linked to disturbances in mentalization and the capacity for exchange with one’s social environment, which are main foci in current psychotherapeutic approaches in SSD [61–64]. An important finding of our study is also that psychosis itself can feature, at least in part, as a positive experience, temporarily resolving the ambivalence, existential anxiety and numbing sadness characteristic of our patients’ pre-psychotic everyday lives: the immediate knowing (apophany) that Conrad [43] described as characteristic of the initial phase of psychosis in terms of delusional meaning-making is experientially very akin to the feeling of ‘flow’ our participants described in terms of emotional immersion and contact with their authentic selves. This immersion was, however, not enacted in interpersonal emotional contexts [7, 8, 10] or masterful practicing of art [65] as is normally the case, but took the form of solipsistic revelation [66] (this ‘revelatory’ quality of psychosis is often compared to mystical experiences in the literature [67, 68]).
Emotion Experience in Psychosis
Psychopathology DOI: 10.1159/000357759
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valences. Following the phenomenological analysis of Lambie and Marcel [7], we could posit that there is diminished immersion in our patients’ emotions, which is reflected in both the evaluative description and the action attitude components of EmEx: evaluative descriptions seem to be unstable and action attitudes weakened. Though our patients may label a certain EmEx as ‘joy’ (see Results, section ‘Emotional buffer, ...’), there is rarely subjective certainty about the nature of this experience: they are not sure what this ‘joy’ tells them about a given situation nor how they should act on it. Intensive affectivity lacking meaningful integration of evaluative descriptions and action attitudes contributes greatly to the aforementioned ambivalence [46] in SSD from a clinical point of view. Our data also fits well into the general phenomenological framework of SSD as diminished self-presence [2] and the theoretical formulation of emotionality in SSD as non-emotional affectivity, as described by Sass [16]. He argues that there is a decline of emotion proper in SSD but not affectivity in general: affects in SSD are more akin to mood than to emotion as they lack both a specific target in the world and a motoric action-orientation. Our findings closely parallel Sass’s conceptualization and add insight into the process of ‘de-emotionalization’ and the role anxiety plays in it. It should be acknowledged that subjective emotional disturbances specific to schizophrenia have been dealt with extensively in the psychoanalytic literature [49]. Subjective uncertainty in identifying emotions is also captured by the EASE item ‘inability to distinguish modalities of intentionality’ (EASE, developed by Parnas et al. [50], is a validated instrument for assessing anomalous self-experience in SSD [51]). The perturbing nature of EmEx described by our subjects is in line with research on affective reactivity in SSD [20] and seems to be most prominent in interpersonal emotional situations. It is probable that unstable evaluative descriptions and weakened action attitudes contribute to both diminished emotional expression [15, 18, 19] and disturbed understanding of interpersonal contexts [52]. If we consider the reported association between social anxiety and poor mentalizing capabilities [30, 31] on the one hand and the perturbing effect emotionally laden experiences/memories have on cognition [20–22] on the other, it seems probable that anxiety (as buffer) plays a common role in the deconstruction of both EmEx and social cognition. The described lack of subjective certainty in a given emotional situation exacerbates the pervasive anxiety of
This finding has important therapeutic implications because clinicians are too often inclined to reduce the psychotic experience to aberrant neurochemistry or faulty cognition, with little or no positive implications for treatment. Our analyses suggest that these experiences
carry great subjective significance for the patient and may serve as valuable footholds for psychotherapeutic interventions, whatever the psychotic disorder’s aetiology or overall developmental mechanism may be.
References
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18 Trémeau F: A review of emotion deficits in schizophrenia. Dialogues Clin Neurosci 2006; 8:59–70. 19 Phillips LK, Seidman LJ: Emotion processing in persons at risk for schizophrenia. Schizophr Bull 2008;34:888–903. 20 Docherty NM, Evans IM, Sledge WH, Seibyl JP, Krystal JH: Affective reactivity of language in schizophrenia. J Nerv Ment Dis 1994; 182: 98–102. 21 Danion JM, Cuervo C, Piolino P, Huron C, Riutort M, Peretti CS, et al: Conscious recollection in autobiographical memory: an investigation in schizophrenia. Conscious Cogn 2005;14:535–547. 22 Neumann A, Blairy S, Lecompte D, Philippot P: Specificity deficit in the recollection of emotional memories in schizophrenia. Conscious Cogn 2007;16:469–484. 23 Maggini C, Raballo A: Alexithymia and schizophrenic psychopathology. Acta Biomed 2004;75:40–49. 24 Baslet G, Termini L, Herbener E: Deficits in emotional awareness in schizophrenia and their relationship with other measures of functioning. J Nerv Ment Dis 2009; 197: 655– 660. 25 Pallanti S, Cantisani A, Grassi G: Anxiety as a core aspect of schizophrenia. Curr Psychiatry Rep 2013;15:354. 26 Muller JE, Koen L, Soraya S, Emsley RA, Stein DJ: Anxiety disorders and schizophrenia. Curr Psychiatry Rep 2004;6:255–261. 27 Achim AM, Maziade M, Raymond E, Olivier D, Mérette C, Roy MA: How prevalent are anxiety disorders in schizophrenia? A metaanalysis and critical review on a significant association. Schizophr Bull 2011;37:811–821. 28 Voges M, Addington J: The association between social anxiety and social functioning in first episode psychosis. Schizophr Res 2005; 76:287–292. 29 Michail M, Birchwood M: Social anxiety disorder in first-episode psychosis: incidence, phenomenology and relationship with paranoia. Br J Psychiatry 2009;195:234–241. 30 Achim AM, Ouellet R, Lavoie MA, Vallières C, Jackson PL, Roy MA: Impact of social anxiety on social cognition and functioning in patients with recent-onset schizophrenia spectrum disorders. Schizophr Res 2013; 145: 75– 81.
31 Lysaker PH, Erickson M, Ringer J, Buck KD, Semerari A, Carcione A, Dimaggio G: Metacognition in schizophrenia: the relationship of mastery to coping, insight, self-esteem, social anxiety, and various facets of neurocognition. Br J Clin Psychol 2011;50:412–424. 32 Pallanti S, Quercioli L, Hollander E: Social anxiety in outpatients with schizophrenia: a relevant cause of disability. Am J Psychiatry 2004;161:53–58. 33 Braga RJ, Mendlowicz MV, Marrocos RP, Figueira IL: Anxiety disorders in outpatients with schizophrenia: prevalence and impact on the subjective quality of life. J Psychiatr Res 2005;39:409–414. 34 Moustakas C: Phenomenological research methods. Thousand Oaks, Sage, 1994. 35 Wing JK, Babor T, Brugha T, Burke J, Cooper JE, Giel R, et al: SCAN. Schedules for clinical assessment in neuropsychiatry. Arch Gen Psychiatry 1990;47:589–593. 36 Whitley R, Crawford M: Qualitative research in psychiatry. Can J Psychiatry 2005; 50: 108– 114. 37 Handest P, Parnas J: Clinical characteristics of first-admitted patients with ICD-10 schizotypal disorder. Br J Psychiatry Suppl 2005; 48:s49–s54. 38 Parnas J, Licht D, Bovet P: Cluster A personality disorders: a review; in Maj M, Akiskal HS, Mezzich JE, Okasha A (eds): Personality Disorders. WPA Series: Evidence and Experience in Psychiatry. Chichester, Wiley, 2005, pp 1–74. 39 Møller P, Husby R: The initial prodrome in schizophrenia: searching for naturalistic core dimensions of experience and behavior. Schizophr Bull 2000;26:217–232. 40 Lysaker PH, Lysaker JT: Narrative structure in psychosis. Theory Psychol 2002; 12: 207– 220. 41 Smith JA, Osborn M: Interpretative phenomenological analysis; in Smith JA (ed): Qualitative Psychology: a Practical Guide to Research Methods, ed 2. London, Sage, 2008, pp 51–80. 42 Bovet P, Parnas J: Schizophrenic delusions: a phenomenological approach. Schizophr Bull 1993;19:579–597. 43 Conrad K: Die beginnende Schizophrenie. Stuttgart, Thieme, 1958. 44 Heidegger M: What is metaphysics?; in Krell DF (ed): Martin Heidegger: Basic Writings. New York, Harper Collins, 1993, pp 89–110.
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1 Sass LA: Self and world in schizophrenia: three classic approaches. Philos Psychiatr Psychol 2001;8:251–270. 2 Sass LA, Parnas J: Schizophrenia, consciousness, and the self. Schizophr Bull 2003; 29: 427–444. 3 Sass LA, Parnas J, Zahavi D: Phenomenological psychopathology and schizophrenia: contemporary approaches and misunderstandings. Philos Psychiatr Psychol 2011;18:1–23. 4 Fuchs T: Corporealized and disembodied minds: a phenomenological view of the body in melancholia and schizophrenia. Philos Psychiatr Psychol 2005;12:95–107. 5 Gibson J: The Ecological Approach to Visual Perception. Boston, Houghton Mifflin, 1979. 6 De Sousa R: Truth, authenticity, and rationality. Dialectica 2007;61:323–345. 7 Lambie J, Marcel A: Consciousness and emotion experience: a theoretical framework. Psychol Rev 2002;109:219–259. 8 Sartre JP: Esquisse d’une théorie phénomenologique des émotions. Paris, Hermann, 1939. 9 Merleau-Ponty M: The Phenomenology of Perception. New York, Routledge & Kegan Paul, 1962. 10 Frijda NH: Emotion experience. Cogn Emot 2005;19:473–497. 11 Lake CR: Hypothesis: grandiosity and guilt cause paranoia; paranoid schizophrenia is a psychotic mood disorder; a review. Schizophr Bull 2008;34:1151–1162. 12 Ciompi L: The concept of affect logic: an integrative psycho-socio-biological approach to understanding and treatment of schizophrenia. Psychiatry 1997;60:158–170. 13 Bouricius JK: Negative symptoms and emotions in schizophrenia. Schizophr Bull 1989; 15:201–208. 14 Sweet LH, Primeau M, Fichtner CG, Lutz G: Dissociation of affect recognition and mood state from blunting in patients with schizophrenia. Psychiatry Res 1998;81:301–308. 15 Kring AM, Kerr SL, Smith DA, Neale JM: Flat affect in schizophrenia does not reflect diminished subjective experience of emotion. J Abnorm Psychol 1993;102:507–517. 16 Sass LA: Contradictions of emotion in schizophrenia. Cogn Emot 2007;21:351–390. 17 Sass LA: Affectivity in schizophrenia: a phenomenological view. J Conscious Stud 2004; 11:127–147.
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53 Laing RD: The divided self: an existential study in sanity and madness. London, Tavistock, 1960. 54 Corin E: The thickness of being: intentional worlds, strategies of identity, and experience among schizophrenics. Psychiatry 1998; 61: 133–146. 55 Winnicott DW: The maturational processes and the facilitating environment: studies in the theory of emotional development. London, Carnac, 1990. 56 Kohut H, Wolf ES: The disorders of the self and their treatment: an outline. Int J Psychoanal 1978;59:413–425. 57 Wittmann D, Keshavan M: Grief and mourning in schizophrenia. Psychiatry 2007; 70: 154–166. 58 Birchwood M, Iqbal Z, Chadwick P, Trower P: Cognitive approach to depression and suicidal thinking in psychosis. 1. Ontogeny of post-psychotic depression. Br J Psychiatry 2000;177:516–521. 59 Iqbal Z, Birchwood M, Chadwick P, Trower P: Cognitive approach to depression and suicidal thinking in psychosis. 2. Testing the validity of a social ranking model. Br J Psychiatry 2000;177:522–528.
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60 Williams CC: Insight, stigma, and post-diagnosis identities in schizophrenia. Psychiatry 2008;71:246–256. 61 Rosenbaum B, Harder S: Psychosis and the dynamics of the psychotherapy process. Int Rev Psychiatry 2007;19:13–23. 62 Stanghellini G, Lysaker PH: The psychotherapy of schizophrenia through the lens of phenomenology: intersubjectivity and the search for the recovery of first- and second-person awareness. Am J Psychother 2007; 61: 163– 179. 63 Fuchs T: Psychotherapy of the lived space: a phenomenological and ecological concept. Am J Psychother 2007;61:423–439. 64 Brent B: Mentalization-based psychodynamic psychotherapy for psychosis. J Clin Psychol 2009;65:803–814. 65 Csikszentmihalyi M: Flow: the psychology of optimal experience. New York, Harper Collins, 1990. 66 Parnas J, Sass LA: Self, solipsism and schizophrenic delusions. Philos Psychiatr Psychol 2001;8:101–120. 67 Brett C: Psychotic and mystical states of being: connections and distinctions. Philos Psychiatr Psychol 2002;9:321–341. 68 Podvoll EM: Psychosis and the mystic path. Psychoanal Rev 1979–1980;66:571–590.
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45 Ratcliffe M: Feelings of being: phenomenology, psychiatry and the sense of reality. New York, Oxford University Press, 2008. 46 Bleuler E: Dementia praecox or the group of schizophrenias. Oxford, International Universities Press, 1950. 47 Störring G: Perplexity; in Cutting J, Shepherd M (eds): Clinical roots of the schizophrenia concept. Cambridge, Cambridge University Press, 1987, pp 79–82. 48 Henriksen MG, Škodlar B, Sass, LA, Parnas J: Autism and perplexity: a qualitative and theoretical study of basic subjective experiences in schizophrenia. Psychopathology 2010; 43: 357–368. 49 Deutsch H: Some forms of emotional disturbance and their relationship to schizophrenia. Psychoanal Q 1942;11:301–321. 50 Parnas J, Møller P, Kircher T, Thalbitzer J, Jansson L, Handest P, et al: EASE: Examination of Anomalous Self-Experience. Psychopathology 2005;38:236–258. 51 Raballo A, Parnas J: Examination of Anomalous Self-Experience: initial study of the structure of self-disorders in schizophrenia spectrum. J Nerv Ment Dis 2012;200:577–583. 52 Hemsley DR: The development of a cognitive model of schizophrenia: placing it in context. Neurosci Biobehav Rev 2005;29:977–988.
Psychopathology DOI: 10.1159/000357759
The Phenomenology of Emotion Experience in First-Episode Psychosis V.V. Vodušek a J. Parnas b M. Tomori a B. Škodlar a a
University Psychiatric Hospital Ljubljana, Ljubljana, Slovenia; b Center for Subjectivity Research, Copenhagen, Denmark
Abstract Background: Although it has been suggested that disturbances in emotion experience and regulation play a central role in the aetiology and psychopathology of schizophrenia spectrum disorders, the phenomenology of emotion experience in schizophrenia remains under-researched. Sampling and Methods: In-depth interviews were conducted twice with each of the 20 participants (firstly at admission and secondly 6 months later). Data collection and analysis were guided by the principles of phenomenological study of lived experience. Results: The emotion experiences described by our participants vary greatly in both quality and intensity, but appear to have a common phenomenology. Anxiety is reported as the basic emotion which buffers, transforms and sometimes supplants all others. Emotions in general are experienced as foreign, unstable and perturbing, thereby contributing greatly to feelings of ambivalence, perplexity and an unstable sense of self in general. Conclusions: The findings of this study have important therapeutic and theoretical implications because they suggest that emotion experiences in schizophrenia spectrum disorders may underlie a wide range of psychopathological phenomena in both the cogni-
© 2014 S. Karger AG, Basel 0254–4962/14/0000–0000$39.50/0 E-Mail [email protected] www.karger.com/psp
tive and social functioning domains. Due to the relatively small sample size and its selection from psychotherapeutic units, the results may not be generalizable to all schizophrenia patients. © 2014 S. Karger AG, Basel
Introduction
The Phenomenology of Schizophrenia Spectrum Disorders and the Phenomenology of Emotion Experience Picking up the legacy of mid-20th-century European phenomenological psychiatry [1], contemporary phenomenological psychopathology conceives the core of schizophrenia spectrum disorders (SSD) to inhere in a specific alteration of the structure of conscious experience (the ipseity disturbance model [2, 3]). The basic structure of subjectivity (consciousness), underpinning all reflection and self-world interactions is ipseity: all experience is given to me as my experience, i.e. it displays a basic character of first-personal givenness, ‘mine-ness’ or ‘for-me-ness’ [3]. The ipseity disturbance model proposes that SSD in their various presentations are characterized by an instability of this basic experiential structure. The ipseity disturbance involves an interplay of diminished self-affection and hyper-reflexivity [3]. Diminished self-affection V.V. Vodušek University Psychiatric Hospital Ljubljana Studenec 48 SI–1260 Ljubljana (Slovenia) E-Mail vvvodusek @ gmail.com
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Key Words Phenomenology · Emotion · Subjective experience · Psychosis · Schizophrenia spectrum disorders · Ipseity disturbance
EmEx in SSD Although it has been proposed that disturbances in EmEx are a core feature of paranoid schizophrenia [11] and SSD in general [12], the phenomenology of EmEx in SSD remains under-researched. Aiming to bridge the paradox of simultaneous emotional hypo- and hyper-sensitivity observed in (predominantly negative) SSD [13–15], Sass [16, 17] conceptualizes EmEx disturbance in terms of 2
Psychopathology DOI: 10.1159/000357759
‘non-emotional affectivity’ (emotionality proper is diminished while other – non-emotional – forms of affective response are preserved or even heightened). Quantitative studies show that emotional expression is diminished in SSD, but in the areas of recognition and experience of emotions the results are widely inconclusive: the only robust finding is that people with SSD tend to have a negative bias in both areas (compared to controls, they experience more negative emotions and are more prone to perceiving emotional stimuli as negative) [18, 19]. More consistent findings have been reported: (1) on the disorganizing effect of (especially negative) affect-laden topics on speech production [20] and (2) on the disturbance of autobiographical [21] and emotional [22] memory in SSD. When conversing on or recalling topics that elicit EmEx, the specificity and coherence of the narrative produced in SSD is markedly impaired. Alexithymia [23] and reduced emotional awareness [24] have also been shown to be a trait characteristic in SSD. The above findings imply a negative bias in and a disturbed grip on EmEx in SSD: patients experience more negative and disturbing emotions than controls, and they are less able to discriminate between different emotions, both of which seems to contribute to a disorganizing effect of EmEx on cognition. Anxiety and Social Anxiety in SSD and Their Impact on Social Cognition and Metacognition From among the various emotional/affect states in SSD, anxiety is the only one that has been extensively researched and is even considered by some to be the core symptom of SSD [25, 26]. A recent meta-analytic study has estimated the prevalence of different anxiety disorders in SSD at 10–20% [27], with some studies reporting elevated levels of social anxiety in first-episode psychosis in up to 60% of participants [28, 29]. Social anxiety in SSD is associated with greater deficits in mentalizing and social cognition in general [30], worse performance on metacognitive tasks [31] and, consequently, greater disability in social functioning [28, 30, 32] and poorer quality of life [33]. Methods Data collection and analysis were guided by two main principles of phenomenological study of lived experience: (1) exclusive and detailed focus on the subjective experience as described and interpreted by participants and (2) suspension of theoretical pre-
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may manifest itself as a lack of a vital support from the lived body and a sense of disconnectedness from the world: feelings of disembodiment [4], sense of ephemeral existence, and overall alienation from one’s own subjectivity. The world appears as if lacking affordances [5] (meaning), the subject feels not real and lacking action potential. The ‘mine-ness’ quality of subjective experience is manifested in what we can call the ‘Janus-face’ [6] of emotion experience (EmEx): the world appears to me in a certain way by dint of the emotional state I find myself in (and vice versa). The phenomenological manifestation of EmEx always involves a certain evaluative component and a felt action attitude [7]: I don’t become angry because somebody is perceived as offensive, and I don’t feel the tendency to retaliate because I am angry. The perception of somebody as offensive and the felt tendency to retaliate is exactly what constitutes anger. It is the totality of a given EmEx which constitutes and presents a given self-world relation for the subject; in immersed states of EmEx the perceptual and conceptual field can be completely transformed, which Sartre called the ‘magical’ property of emotions [8]. EmEx vary greatly in intensity and duration, detachment versus immersion and the general directedness of attention toward the self, others or the world, articulated as a figure-ground gestalt [7]: in immersed states one cannot experience the world and the self simultaneously, as one always displaces the other. The pre-reflective phenomenology of anger is experienced either as ‘self-as-offended’ or as ‘bastard-deserving-of-retaliation’. It is only in the more detached and analytic mode of reflective consciousness that one can bring focal attention to bear selectively on one or the other aspect of a given EmEx figure-ground articulation. If the lived body [9] is a set of innumerable potentialities that can be realized through the world’s affordances, it is EmEx that place the self in specific impelling relations to the world. The world appears as meaningful in this or that respect by its emotional salience and the responses called for [10].
Age, years
Gender (male)
Schooling, years
Untreated psychosis, months
22.1 ± 4.9
60%
13.6 ± 3.2
10.9 ± 6.4
Values are presented as means ± SD.
suppositions on the subject matter (epoché) in the investigative effort of the researcher [34]. Sample The sample consists of 20 first-episode (non-affective) psychosis patients consecutively admitted to the Unit for the Psychotherapy of Psychoses and the Unit for Adolescent Psychiatry in the Centre for Mental Health of the University Psychiatric Clinic Ljubljana, who were diagnosed by a senior clinician (B.Š.) on the basis of a Present State Examination clinical interview [35]. The following were excluded: (1) patients abusing psychoactive substances and (2) those with a known psychosis-inductive organic disorder. All patients were sufficiently organized in speech and thought (i.e. in the main, past the acutely psychotic phase) to be able to participate in the intensive psychotherapeutic programme. All participants signed statements of informed consent. The study was approved by the national bioethics committee. Table 1 shows the age, gender, years of schooling, and duration of untreated psychosis of the participants. Procedure In-depth interviews were conducted in an open-ended and loosely structured manner that allowed for: (1) spontaneous unfolding of the participants’ narratives and (2) gradual crystallization of the basic experiential elements through hermeneutic dialogue [36]. A given interview lasted from 1 to 4 h depending on: (1) the quantity of elicited material and (2) the participant’s appreciation of the hermeneutic dialogue, i.e. the degree to which additional probing yielded new aspects to the experiential gestalt at hand. A single interview session never lasted more than 1 h, which means that longer interviews were conducted over several sessions. The two main foci of the interviews were: (1) the quality of EmEx as they arise in the everyday life of the participant and (2) the relation of these EmEx to the basic sense of self of the participant. The interviewer did not operate with a pre-defined set of questions but tried to access EmEx indirectly via exploration of personal narratives. The participants were neutrally encouraged to talk about their everyday experiences, and the interview then gradually focusing on the EmEx that were involved in a given narrative fragment. As ipseity disturbance is not delimited to schizophrenia alone but underlies a specific way of being-in-the-world for the whole spectrum [37, 38], the participants were asked to describe their EmEx before, during and after psychosis. Regarding the pre-psychotic EmEx, the participants were asked to describe their most
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self-defining emotional memories with no time interval constraints. As it has been shown that pre-psychotic personal narratives are usually engulfed by psychosis and its aftermath [39, 40] and so cannot be comprehensively accessed at the time directly following decompensation, the interviews were conducted twice with each participant: firstly at admission and secondly 6 months later. All interviews were transcribed verbatim and analysed by the first author, the analysis being guided by the principles of phenomenological hermeneutics [41]: following several re-readings to obtain a grip on the overall organization of the experiential field at hand, the main themes were identified and coded; then common experiential denominators of these themes were extracted and lastly a synthesis was attempted for phase-specific EmEx gestalts and their relation to the sense of self. For purposes of reliability, the last author analysed eight randomly selected interviews de novo, then the results of both analyses were compared and scrutinized. As inter-subjective consensus regarding the selected interviews was high, the remainder of the interviews were discussed on the basis of the first author’s verbal report. An agreement was reached concerning relevant interpretive incongruences, so that the final results represent a consensus between the two authors.
Results
The main findings of the study will be presented in the order of relevance and salience as experienced and reported by the participants, but firstly we must acknowledge the development of themes across the two interviews: the pre-psychotic way of being-in-the-world seemed experientially distant and ‘in another world’ for the participants in the first round of interviews. They could describe the crude outlines of their familial, social and academic- or work-related functioning, but seemed hard-pressed when asked about more specific EmEx. They seemed partially aware of the oddness of this predicament, but explained it off as ‘poor memory’ and assured the interviewer that their past was nothing like what they were experiencing now. The participants, who were interviewed over several sessions in the first round, regained some contact with their past, but only in experiential fragments, so that a more comprehensive gestalt of EmEx in question emerged only by the second round of interviews. Emotional Emptiness and the Sense of Loss and of Being Lost in the Post-Psychotic Self EmEx in the post-psychotic phase were generally described in terms of loss and of being lost. The vast majority of participants described loss of emotions leading to diminished vitality and motivation. Intimate relationPsychopathology DOI: 10.1159/000357759
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Table 1. Sample characteristics
‘I used to be more emotional than I am now. In relation to the problems of other people for example: I haven’t been feeling any sympathy lately. Even if I see something really bad on TV, something that would have made me want to weep in the past, it doesn’t affect me at all now. It’s as though I am empty inside.’
This emotional emptiness is not experienced as a void but rather as a present absence: although most participants affirm that they feel ‘nothing’, this is always experienced as a missing out of ‘something’ that they used to feel, or rather something that they ought to feel. It is never a lack of feeling per se, but merely a lack of distinctive EmEx: there is always a feeling present, but it is hard for the participants to communicate it, because it does not take a definite form. It is described alternatively as tension, pressure, vulnerability or a fear of everything. None of the participants originally used the term ‘anxiety’, but most of them welcomed it as an apt description. This presence of anxiety appears as a flip side to emotional emptiness and is experienced as a constant background of everyday life in the post-psychotic phase. All but 5 of the participants experience an amplification of this basic anxiety in situations that used to elicit more definite EmEx in the past. ‘I used to like driving my car, living in my own apartment, talking with friends, but now I feel as though I have to start from scratch and learn everything anew: I am afraid to drive, afraid to stay alone in my apartment, afraid to accept an invitation for a drink with a friend. I have to force myself to try these things as though I had never done them before.’
Distinctive EmEx which normally provide orientation and motivation are dissolved into an amorphous and unnerving sense of overwhelming anxiety that renders the subject lost and immobile; this state was aptly described by one of the participants as ‘frozen between fight and flight’. Emotional emptiness is alternatively described as a ‘loss of contact’ both with the world and its affordances and with the self and its potentials: by dint of the world failing to transpire as something to be happy, sad or angry about, the sense of self also remains opaque. All but 3 of the participants describe a pervasive sense of insecurity about themselves most commonly called ‘bad self-image’. They don’t feel less worthy than other people, however, but lack a stable reference frame of self-to-world altogether. In the same way as they feel estranged in (social) interactions for lack of (interpersonal) emotional attunement, 4
Psychopathology DOI: 10.1159/000357759
they also feel perplexed about themselves as (social) beings: they don’t know whether they are amusing or boring, able or unable, welcome or unwelcome. This loss of contact with the self and the world makes for an overall sense of being lost. ‘I don’t know what to say and how to respond when I’m with friends. They laugh at my jokes but I can never tell if they’re not just being nice and pretending to be amused ... I don’t know what I’m good at or even what I want to do in my life: I often wonder whether there even is a job for my profile ...’
This sense of being lost is accompanied by overwhelming feelings of hopelessness, which are usually described as ‘depression’ as they often entail suicidal ideation. When more closely examined, however, participants never describe feeling sadness as sadness, but rather as an amplification of the basic anxiety that they wish would be sadness, so they could release themselves of it by mourning and weeping. ‘I am never really sad, because I am emotionally numb. I feel a certain sadness almost all the time though – I’m sad because of this numbness. I often wish I could weep, feel this sadness fully, but I can’t ... there is always just this feeling of numbing tension.’
Emotional Buffer, Lack of Flow and Mourning for Authenticity in the Pre-Psychotic Self The overarching theme of the pre-psychotic way of being-in-the-world is that of an emotional buffer in relation to the self, world and others. The participants described this emotional buffer alternatively as a ‘bubble’ surrounding them, a ‘curtain’ in the way of EmEx, or a state of being ‘comfortably numb’. The emotional buffer was reported as present from the very start of puberty (from around 12–14 years of age). The emotional buffer does not imply a simple subtraction of EmEx intensity and/or duration, but rather diminished immersion. Most of the participants usually recognized the emotion that a given self/world evaluation and felt action tendency implied, but rarely ever felt that they were present in and in contact with the experience. EmEx is ‘detected’, but not inhabited: it skims the periphery of consciousness as a wave going by – a wave they wish to ride and be one with, but can’t. As with emotional emptiness, the emotional buffer effects itself as a presence, again most aptly described as anxiety. ‘This sense of numbness is always present to some extent – it is a tension and a scatteredness of attention in everything I do and everyone I meet ... like I wasn’t fully connected, like there is a buffer.’
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ships no longer elicited feelings of warmth and comradeship, jokes that made them laugh or movies that made them weep no longer stirred discernible emotions in them.
Buffered through anxiety, joy isn’t experienced as inhabited joy, but as a sense of crude euphoria that is somehow foreign to and forced upon the subject. This implies a potential for negative interaction between anxiety (that buffers EmEx in the first place) and EmEx: the advent of a given EmEx (estranged by the buffer) exacerbates both the initial anxiety and the potential for immersion, inciting the subject to ‘get it over with’, ‘do something about it’, i.e. withdraw from EmEx altogether. EmEx are highly ambivalent as they are experienced both as a missing out, as something that should be there but isn’t, and as a perturbation, as something to be gotten over and done with. The participants describe a lack of ‘calm’ and ‘immersion’ in their EmEx, which constitutes lack of contact with oneself and one’s environment, or as one participant put it: not being ‘in the flow’. This feeling of deficit can compel the subject to attempt to ‘amplify’ the EmEx called for in a given interpersonal situation by conscious effort, which further exacerbates the sense of ‘not-being-oneself’ and may incite fear of being declared a ‘fake’. ‘I feel the emotions but in a very attenuated way. Sometimes I have the feeling that I have to amplify a certain emotion; I try to hold on to it, grab it before it gets away. I think others are more spontaneous in this, it comes to them more freely and stronger. Because others aren’t familiar with this (particular quality of EmEx), they might think that I’m just faking it, that I don’t really have the emotions I show.’
The emotional buffer makes for an overall sense of lack of authenticity and realness of self, which contributes to a general mood reflecting the ambivalence of particular EmEx: most of the participants describe an ever-present combination of burdening numbness and estrangement on one side and an undifferentiated sadness and mourning for the perceived lack of contact on the other. ‘I’m not in contact, I don’t feel present as a person, don’t have a sensation of myself. I feel like a ghost – in the sense that I am not inside (myself). I am here physically but not psychically... I tried to weep, but I just can’t. It just doesn’t connect: it’s just like ‘ǝǝǝǝǝ’ (= a muffled sound), like there was a pillow in between ... I often tried weeping, just for being in this state, just to get out of it.’
Emotion Experience in Psychosis
This seems like a paradox: there is both a sense of diminishment of ‘presence in’ or ‘contact with’ sadness, and mourning for this very diminishment. It seems as though the sense of a diminished capacity for mourning serves as the basis for mourning itself. Full Contact, Emotional Overwhelming and Fear of Annihilation in the Psychotic Self Contrary to the sense of buffered presence or loss of presence characteristic of the pre- and post-psychotic person, the advent of psychosis is experienced by the vast majority of participants as an internal release of tension, a lifting of the ‘curtain’, a rebirth of the authentic subject that is only now allowed full contact with the self. ‘It felt as if a certain tension in the back of my brain was released, as if something collapsed back there, that was creating tension ... it seemed as if I was born anew.’ ‘It was a very powerful experience: I came in full contact with emotions that were suppressed in a distant past. It was as if certain channels opened that had been closed and dusty for a long time; like I was in contact with my true self again.’
This ‘coming into contact’ entailed various delusional and hallucinatory experiences that we shall not expound on, as this has been dealt with extensively in the phenomenological account [42, 43]. What is crucial here is that the advent of psychosis is experienced in more than half of the participants as being at one with oneself (sorely lacking in the pre- and post-psychotic self), positive emotional immersion of an undifferentiated sort and an absence of numbing sadness. ‘In the beginning I was feeling good and full of hope, at times ecstatic. I had the feeling that if I tried hard enough, I could change into a better person, and help make the world a better place.’
This feeling of ‘full contact’ is accompanied by a sense of being in control and a strong feeling of will and a certainty that change is possible: a change of the self and/or a change in the world. As time passes, however, this experiential field is turned outside-in, and the subject feels haunted by the very world he seemed to control, great fear of punishment or annihilation overwhelms him, and as all sense of temporality is lost, so also change becomes merely an article of faith – of hope against hope. If they never felt quite at home in the world that had presented itself through a veil of anxiety in the pre-psychotic phase, in the catastrophic phase of psychosis the world seems completely changed, foreign and threatening. ‘I didn’t recognize the environment anymore, like I couldn’t orient myself, it all seemed foreign – this made the fear even worse. When I went to the police station, I didn’t know whether they were
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‘When I come home, I never feel a certain warmth, a sense of safety. I always feel, not exactly in danger, but not relaxed or at home with myself and others. When a friend comes by joyful about something and wanting to do something, I mean I am also joyful about it although I don’t really know joy ... with me it’s more like a euphoria: it comes just like that, from nowhere ... so I would go ‘Yeah, let’s do it!’, but just to do something about it, to change something; there is never calm in my emotions.’
The interesting thing is that although all participants recognized the psychotic episode as an experiential anomaly, most of them nevertheless resisted reducing it to a neurochemical abnormality or a disease in the sense of something foreign that needs to be eliminated. Although their psychosis also entailed great suffering, all but 6 of the participants still seemed to find an important personal value in the overall experience: as though the sense of flow and hope they experienced in initial psychosis served as a sort of private proof that they are capable of full contact and authenticity. They remained ambivalent about this contact, however, both because of the phantasmagoric landscape it led into and because of the gradual recognition that this contact was also in a way false, because it did not involve real persons, real actions and, consequently, real emotions. ‘It all seemed very real, the different energies that I wanted to get in touch with. But at the same time I never really felt that I was truly in contact with them. It all remained somehow superficial and metaphysical, as if on another energy level – it lacked human warmth.’
It seems that the buffered quality of EmEx did not altogether disappear in the psychotic break, but rather that the intensity of EmEx amplified to such a degree that they substantially overshadowed the buffer’s effect.
Discussion
We wish to emphasize that the recruitment from psychotherapeutically oriented units might have resulted in a biased sample in terms of lesser comorbidity and lower severity. However, such trade-off was necessary and does not pre-empt our main goal of mapping emotional experiences in SDD. Using the narrative approach, we are, by definition, limited to participants’ reports and interpretations of experiences that are accessible to memory and reflection. All our inferences about the nature of EmEx – especially those pertaining to EmEx long past, i.e. from the pre-psychotic phase – must therefore be qualified to a certain extent, as we cannot be sure to what degree they reflect disturbances of (autobiographic) memory [21, 22]. It must also be noted that the inferences presented here necessarily reflect the theoretical and professional back6
Psychopathology DOI: 10.1159/000357759
ground of the authors – others may well have reached different conclusions from the same material. We believe, however, that we have minimized both potential sources of error by limiting ourselves as closely as possible to what is common to most of the experiences described by the participants (which also means that we have sought to highlight what is common to both past and recent memories/experiences). Our analysis of EmEx in SSD is in line with the two general findings in the literature: (1) there is a prevalence of negative EmEx (especially anxiety and undifferentiated sadness) in both the pre- and post-psychotic self [18, 19] and (2) EmEx in general are both subjectively unstable and hard to access [21–24] and have a disorganizing effect on reflective processes [20]. Consistent with other studies [27–29], anxiety appears to be the most prevalent and basic EmEx in SSD: it is not tied to any one concrete situation but pervades, transforms, and sometimes supplants, all other EmEx. It has no one definite object but rather entails a drawing away from all things (including oneself), making for an overall feeling of uncanniness or ‘not-at-homeness’: following the analysis of angst of Heidegger [44], Ratcliffe [45] describes this kind of EmEx as existential feelings (an everpresent backdrop to experience and thought that affects both but has itself no concrete object or intention), which are prominent in psychiatric disorders, typically in SSD. Anxiety in our sample persists in spite of or is exacerbated by distinct emotions, which forms the essence of what we call emotional buffer and emotional emptiness. There seems to be both a dissociation and a negative interaction between anxiety and other EmEx that appears to be specific to SSD emotionality: anxiety subjectively estranges other EmEx and is itself amplified by the EmEx thusly transformed. These disturbances of EmEx led our subjects to feel disembodied, perplexed and pervasively ambivalent. From the very beginnings of descriptive psychopathology of schizophrenia, ambivalence [46], perplexity [47] and disembodiment [4] feature as core dimensions. These anomalies of EmEx, present in the everyday lives of our patients before and after the psychotic episode, closely parallel the findings of contemporary phenomenological research of basic self-world disturbances in SSD, i.e. anxiety, estrangement and exposure [48]. Our analysis suggests that the EmEx described by our participants have a common phenomenology: joy is experienced as crude euphoria, sadness as undifferentiated burdening numbness, etc. Under the label ‘emotions’ participants describe a disturbing numbness with variable Vodušek /Parnas /Tomori /Škodlar
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the actual police or whether they were somehow connected with the story (= delusion). When I went to meet my mother in the airport, I wasn’t sure whether it was the XY airport or whether I was somewhere else ...’
our subjects and further destabilizes their sense of basic self: this leads our subjects to different adaptation mechanisms similar to the ones described in the literature as ‘false self systems’ [53] and ‘positive withdrawal’ [54]. The perceived lack of contact with the authentic self, described in the literature as ‘false’ [55] and ‘emptied’ [56] self, is intrinsically related to a pervasive sense of loss, leading to feelings of bare and numbing sadness in our subjects: it would appear that besides anxiety, undifferentiated sadness also features as an existential feeling [45] in SSD, which parallels the conceptualization of psychosis as complicated mourning, as described by Wittmann and Keshavan [57] (in our case, the feeling of ‘being authentic’ is described mainly in terms of contraposition to the emotional buffer: ‘being authentic’ therefore does not imply any definite kind or set of EmEx but a certain qualitative change of EmEx in general, i.e. them being more selfpresent, experienced more directly and close-to-self). The undifferentiated sadness described by our participants seems to have a different phenomenology than depression and is more akin to SSD-specific ‘disembodiment’ than to ‘corporealized melancholia’ [4]. However, we cannot reliably dissociate this undifferentiated sadness from post-psychotic depression [58] in the context of demoralization and stigmatization [59, 60] on the basis of our analysis alone. The emotional buffer and/or emptiness described in this paper are not only a source of pain in themselves, but also present a great obstacle in the achievement of intersubjectivity: subjective uncertainty in the EmEx of own self is closely linked to disturbances in mentalization and the capacity for exchange with one’s social environment, which are main foci in current psychotherapeutic approaches in SSD [61–64]. An important finding of our study is also that psychosis itself can feature, at least in part, as a positive experience, temporarily resolving the ambivalence, existential anxiety and numbing sadness characteristic of our patients’ pre-psychotic everyday lives: the immediate knowing (apophany) that Conrad [43] described as characteristic of the initial phase of psychosis in terms of delusional meaning-making is experientially very akin to the feeling of ‘flow’ our participants described in terms of emotional immersion and contact with their authentic selves. This immersion was, however, not enacted in interpersonal emotional contexts [7, 8, 10] or masterful practicing of art [65] as is normally the case, but took the form of solipsistic revelation [66] (this ‘revelatory’ quality of psychosis is often compared to mystical experiences in the literature [67, 68]).
Emotion Experience in Psychosis
Psychopathology DOI: 10.1159/000357759
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valences. Following the phenomenological analysis of Lambie and Marcel [7], we could posit that there is diminished immersion in our patients’ emotions, which is reflected in both the evaluative description and the action attitude components of EmEx: evaluative descriptions seem to be unstable and action attitudes weakened. Though our patients may label a certain EmEx as ‘joy’ (see Results, section ‘Emotional buffer, ...’), there is rarely subjective certainty about the nature of this experience: they are not sure what this ‘joy’ tells them about a given situation nor how they should act on it. Intensive affectivity lacking meaningful integration of evaluative descriptions and action attitudes contributes greatly to the aforementioned ambivalence [46] in SSD from a clinical point of view. Our data also fits well into the general phenomenological framework of SSD as diminished self-presence [2] and the theoretical formulation of emotionality in SSD as non-emotional affectivity, as described by Sass [16]. He argues that there is a decline of emotion proper in SSD but not affectivity in general: affects in SSD are more akin to mood than to emotion as they lack both a specific target in the world and a motoric action-orientation. Our findings closely parallel Sass’s conceptualization and add insight into the process of ‘de-emotionalization’ and the role anxiety plays in it. It should be acknowledged that subjective emotional disturbances specific to schizophrenia have been dealt with extensively in the psychoanalytic literature [49]. Subjective uncertainty in identifying emotions is also captured by the EASE item ‘inability to distinguish modalities of intentionality’ (EASE, developed by Parnas et al. [50], is a validated instrument for assessing anomalous self-experience in SSD [51]). The perturbing nature of EmEx described by our subjects is in line with research on affective reactivity in SSD [20] and seems to be most prominent in interpersonal emotional situations. It is probable that unstable evaluative descriptions and weakened action attitudes contribute to both diminished emotional expression [15, 18, 19] and disturbed understanding of interpersonal contexts [52]. If we consider the reported association between social anxiety and poor mentalizing capabilities [30, 31] on the one hand and the perturbing effect emotionally laden experiences/memories have on cognition [20–22] on the other, it seems probable that anxiety (as buffer) plays a common role in the deconstruction of both EmEx and social cognition. The described lack of subjective certainty in a given emotional situation exacerbates the pervasive anxiety of
This finding has important therapeutic implications because clinicians are too often inclined to reduce the psychotic experience to aberrant neurochemistry or faulty cognition, with little or no positive implications for treatment. Our analyses suggest that these experiences
carry great subjective significance for the patient and may serve as valuable footholds for psychotherapeutic interventions, whatever the psychotic disorder’s aetiology or overall developmental mechanism may be.
References
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18 Trémeau F: A review of emotion deficits in schizophrenia. Dialogues Clin Neurosci 2006; 8:59–70. 19 Phillips LK, Seidman LJ: Emotion processing in persons at risk for schizophrenia. Schizophr Bull 2008;34:888–903. 20 Docherty NM, Evans IM, Sledge WH, Seibyl JP, Krystal JH: Affective reactivity of language in schizophrenia. J Nerv Ment Dis 1994; 182: 98–102. 21 Danion JM, Cuervo C, Piolino P, Huron C, Riutort M, Peretti CS, et al: Conscious recollection in autobiographical memory: an investigation in schizophrenia. Conscious Cogn 2005;14:535–547. 22 Neumann A, Blairy S, Lecompte D, Philippot P: Specificity deficit in the recollection of emotional memories in schizophrenia. Conscious Cogn 2007;16:469–484. 23 Maggini C, Raballo A: Alexithymia and schizophrenic psychopathology. Acta Biomed 2004;75:40–49. 24 Baslet G, Termini L, Herbener E: Deficits in emotional awareness in schizophrenia and their relationship with other measures of functioning. J Nerv Ment Dis 2009; 197: 655– 660. 25 Pallanti S, Cantisani A, Grassi G: Anxiety as a core aspect of schizophrenia. Curr Psychiatry Rep 2013;15:354. 26 Muller JE, Koen L, Soraya S, Emsley RA, Stein DJ: Anxiety disorders and schizophrenia. Curr Psychiatry Rep 2004;6:255–261. 27 Achim AM, Maziade M, Raymond E, Olivier D, Mérette C, Roy MA: How prevalent are anxiety disorders in schizophrenia? A metaanalysis and critical review on a significant association. Schizophr Bull 2011;37:811–821. 28 Voges M, Addington J: The association between social anxiety and social functioning in first episode psychosis. Schizophr Res 2005; 76:287–292. 29 Michail M, Birchwood M: Social anxiety disorder in first-episode psychosis: incidence, phenomenology and relationship with paranoia. Br J Psychiatry 2009;195:234–241. 30 Achim AM, Ouellet R, Lavoie MA, Vallières C, Jackson PL, Roy MA: Impact of social anxiety on social cognition and functioning in patients with recent-onset schizophrenia spectrum disorders. Schizophr Res 2013; 145: 75– 81.
31 Lysaker PH, Erickson M, Ringer J, Buck KD, Semerari A, Carcione A, Dimaggio G: Metacognition in schizophrenia: the relationship of mastery to coping, insight, self-esteem, social anxiety, and various facets of neurocognition. Br J Clin Psychol 2011;50:412–424. 32 Pallanti S, Quercioli L, Hollander E: Social anxiety in outpatients with schizophrenia: a relevant cause of disability. Am J Psychiatry 2004;161:53–58. 33 Braga RJ, Mendlowicz MV, Marrocos RP, Figueira IL: Anxiety disorders in outpatients with schizophrenia: prevalence and impact on the subjective quality of life. J Psychiatr Res 2005;39:409–414. 34 Moustakas C: Phenomenological research methods. Thousand Oaks, Sage, 1994. 35 Wing JK, Babor T, Brugha T, Burke J, Cooper JE, Giel R, et al: SCAN. Schedules for clinical assessment in neuropsychiatry. Arch Gen Psychiatry 1990;47:589–593. 36 Whitley R, Crawford M: Qualitative research in psychiatry. Can J Psychiatry 2005; 50: 108– 114. 37 Handest P, Parnas J: Clinical characteristics of first-admitted patients with ICD-10 schizotypal disorder. Br J Psychiatry Suppl 2005; 48:s49–s54. 38 Parnas J, Licht D, Bovet P: Cluster A personality disorders: a review; in Maj M, Akiskal HS, Mezzich JE, Okasha A (eds): Personality Disorders. WPA Series: Evidence and Experience in Psychiatry. Chichester, Wiley, 2005, pp 1–74. 39 Møller P, Husby R: The initial prodrome in schizophrenia: searching for naturalistic core dimensions of experience and behavior. Schizophr Bull 2000;26:217–232. 40 Lysaker PH, Lysaker JT: Narrative structure in psychosis. Theory Psychol 2002; 12: 207– 220. 41 Smith JA, Osborn M: Interpretative phenomenological analysis; in Smith JA (ed): Qualitative Psychology: a Practical Guide to Research Methods, ed 2. London, Sage, 2008, pp 51–80. 42 Bovet P, Parnas J: Schizophrenic delusions: a phenomenological approach. Schizophr Bull 1993;19:579–597. 43 Conrad K: Die beginnende Schizophrenie. Stuttgart, Thieme, 1958. 44 Heidegger M: What is metaphysics?; in Krell DF (ed): Martin Heidegger: Basic Writings. New York, Harper Collins, 1993, pp 89–110.
Vodušek /Parnas /Tomori /Škodlar
Downloaded by: Rutgers University Alexander Library 128.6.218.72 - 6/1/2014 5:14:42 AM
1 Sass LA: Self and world in schizophrenia: three classic approaches. Philos Psychiatr Psychol 2001;8:251–270. 2 Sass LA, Parnas J: Schizophrenia, consciousness, and the self. Schizophr Bull 2003; 29: 427–444. 3 Sass LA, Parnas J, Zahavi D: Phenomenological psychopathology and schizophrenia: contemporary approaches and misunderstandings. Philos Psychiatr Psychol 2011;18:1–23. 4 Fuchs T: Corporealized and disembodied minds: a phenomenological view of the body in melancholia and schizophrenia. Philos Psychiatr Psychol 2005;12:95–107. 5 Gibson J: The Ecological Approach to Visual Perception. Boston, Houghton Mifflin, 1979. 6 De Sousa R: Truth, authenticity, and rationality. Dialectica 2007;61:323–345. 7 Lambie J, Marcel A: Consciousness and emotion experience: a theoretical framework. Psychol Rev 2002;109:219–259. 8 Sartre JP: Esquisse d’une théorie phénomenologique des émotions. Paris, Hermann, 1939. 9 Merleau-Ponty M: The Phenomenology of Perception. New York, Routledge & Kegan Paul, 1962. 10 Frijda NH: Emotion experience. Cogn Emot 2005;19:473–497. 11 Lake CR: Hypothesis: grandiosity and guilt cause paranoia; paranoid schizophrenia is a psychotic mood disorder; a review. Schizophr Bull 2008;34:1151–1162. 12 Ciompi L: The concept of affect logic: an integrative psycho-socio-biological approach to understanding and treatment of schizophrenia. Psychiatry 1997;60:158–170. 13 Bouricius JK: Negative symptoms and emotions in schizophrenia. Schizophr Bull 1989; 15:201–208. 14 Sweet LH, Primeau M, Fichtner CG, Lutz G: Dissociation of affect recognition and mood state from blunting in patients with schizophrenia. Psychiatry Res 1998;81:301–308. 15 Kring AM, Kerr SL, Smith DA, Neale JM: Flat affect in schizophrenia does not reflect diminished subjective experience of emotion. J Abnorm Psychol 1993;102:507–517. 16 Sass LA: Contradictions of emotion in schizophrenia. Cogn Emot 2007;21:351–390. 17 Sass LA: Affectivity in schizophrenia: a phenomenological view. J Conscious Stud 2004; 11:127–147.
Emotion Experience in Psychosis
53 Laing RD: The divided self: an existential study in sanity and madness. London, Tavistock, 1960. 54 Corin E: The thickness of being: intentional worlds, strategies of identity, and experience among schizophrenics. Psychiatry 1998; 61: 133–146. 55 Winnicott DW: The maturational processes and the facilitating environment: studies in the theory of emotional development. London, Carnac, 1990. 56 Kohut H, Wolf ES: The disorders of the self and their treatment: an outline. Int J Psychoanal 1978;59:413–425. 57 Wittmann D, Keshavan M: Grief and mourning in schizophrenia. Psychiatry 2007; 70: 154–166. 58 Birchwood M, Iqbal Z, Chadwick P, Trower P: Cognitive approach to depression and suicidal thinking in psychosis. 1. Ontogeny of post-psychotic depression. Br J Psychiatry 2000;177:516–521. 59 Iqbal Z, Birchwood M, Chadwick P, Trower P: Cognitive approach to depression and suicidal thinking in psychosis. 2. Testing the validity of a social ranking model. Br J Psychiatry 2000;177:522–528.
Psychopathology DOI: 10.1159/000357759
60 Williams CC: Insight, stigma, and post-diagnosis identities in schizophrenia. Psychiatry 2008;71:246–256. 61 Rosenbaum B, Harder S: Psychosis and the dynamics of the psychotherapy process. Int Rev Psychiatry 2007;19:13–23. 62 Stanghellini G, Lysaker PH: The psychotherapy of schizophrenia through the lens of phenomenology: intersubjectivity and the search for the recovery of first- and second-person awareness. Am J Psychother 2007; 61: 163– 179. 63 Fuchs T: Psychotherapy of the lived space: a phenomenological and ecological concept. Am J Psychother 2007;61:423–439. 64 Brent B: Mentalization-based psychodynamic psychotherapy for psychosis. J Clin Psychol 2009;65:803–814. 65 Csikszentmihalyi M: Flow: the psychology of optimal experience. New York, Harper Collins, 1990. 66 Parnas J, Sass LA: Self, solipsism and schizophrenic delusions. Philos Psychiatr Psychol 2001;8:101–120. 67 Brett C: Psychotic and mystical states of being: connections and distinctions. Philos Psychiatr Psychol 2002;9:321–341. 68 Podvoll EM: Psychosis and the mystic path. Psychoanal Rev 1979–1980;66:571–590.
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45 Ratcliffe M: Feelings of being: phenomenology, psychiatry and the sense of reality. New York, Oxford University Press, 2008. 46 Bleuler E: Dementia praecox or the group of schizophrenias. Oxford, International Universities Press, 1950. 47 Störring G: Perplexity; in Cutting J, Shepherd M (eds): Clinical roots of the schizophrenia concept. Cambridge, Cambridge University Press, 1987, pp 79–82. 48 Henriksen MG, Škodlar B, Sass, LA, Parnas J: Autism and perplexity: a qualitative and theoretical study of basic subjective experiences in schizophrenia. Psychopathology 2010; 43: 357–368. 49 Deutsch H: Some forms of emotional disturbance and their relationship to schizophrenia. Psychoanal Q 1942;11:301–321. 50 Parnas J, Møller P, Kircher T, Thalbitzer J, Jansson L, Handest P, et al: EASE: Examination of Anomalous Self-Experience. Psychopathology 2005;38:236–258. 51 Raballo A, Parnas J: Examination of Anomalous Self-Experience: initial study of the structure of self-disorders in schizophrenia spectrum. J Nerv Ment Dis 2012;200:577–583. 52 Hemsley DR: The development of a cognitive model of schizophrenia: placing it in context. Neurosci Biobehav Rev 2005;29:977–988.
