Does disturbance of self underlie social cognition deficits in schizophrenia and other psychotic...

Review Article

Does disturbance of self underlie socialcognition deficits in schizophrenia and other

psychotic disorders?Barnaby Nelson,1 Louis A. Sass,2 Andrew Thompson,1 Alison R. Yung,1 Shona M. Francey,1

G. Paul Amminger1 and Patrick D. McGorry1

1ORYGEN Research Centre, University ofMelbourne, Parkville, Victoria, Australia;and 2Department of Clinical Psychology,GSAPP – Rutgers University, Piscataway,New Jersey, USA

Corresponding author: Dr BarnabyNelson, ORYGEN Research Centre,University of Melbourne, 35 Poplar Road(Locked Bag 10), Parkville, Vic. 3052,Australia. Email:[email protected]

Received 19 March 2008; accepted 13November 2008

Abstract

Aim: Although the different ap-proaches to psychosis research havemade significant advances in theirown fields, integration between theapproaches is often lacking. Thispaper attempts to integrate a strandof cognitive research in psychoticdisorders (specifically, social cogni-tion research) with phenomenologi-cal accounts of schizophrenia andother psychotic disorders.

Method: The paper is a criticalinvestigation of phenomenologicalmodels of disturbed selfhood inschizophrenia in relation to cognitivetheories of social cognition in psy-chotic disorders.

Results: We argue that disturbance ofthe basic sense of self, as articulatedin the phenomenological literature,may underlie the social cognitiondifficulties present in psychoticdisorders. This argument is basedon phenomenological thinking aboutself-presence (‘ipseity’) being the

primary or most basic ground for theintentionality of consciousness – thatis, the directedness of consciousnesstowards others and the world. A dis-ruption in this basic ground of con-scious life has a reverberating effectthrough other areas of cognitiveand social functioning. We proposethree routes whereby self-disturbancemay compromise social cognition,including dissimilarity, disruptionof lived body and disturbed mentalcoherence.

Conclusions: If this model is sup-ported, then social cognition difficul-ties may be thought of as a secondaryindex or marker of the more primarydisturbance of self in psychoticdisorders. Further empirical workexamining the relationship betweencognitive and phenomenologicalvariables may be of value in identify-ing risk markers for psychosis onset,thus contributing to early interven-tion efforts, as well as in clarifying theessential psychopathological featuresof schizophrenia and other psychoticdisorders.

Key words: early intervention, phenomenology, psychosis, self, socialcognition.

INTRODUCTIONeip_112 83..93

There have been numerous approaches to research-ing the nature and causes of schizophreniaand other psychotic disorders. Although theseapproaches have made significant advances in theirown fields, integration between the approaches isoften lacking. This paper attempts to integrate astrand of cognitive research (specifically, social cog-nition research) with phenomenological accounts

of schizophrenia and other psychotic disorders.Although the present article is essentially a specula-tive and exploratory effort, the authors believe thatit is through this integrative work that a coherent,comprehensive model of psychotic disorders,including pathogenetic factors, can be developed.1,2

In addition, integrative models are required in orderto ‘make sense’ of the burgeoning research findingsin psychosis research by organizing them into apsychopathological framework.

Early Intervention in Psychiatry 2009; 3: 83–93 doi:10.1111/j.1751-7893.2009.00112.x

© 2009 The AuthorsJournal compilation © 2009 Blackwell Publishing Asia Pty Ltd

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mailto:[email protected]

The paper reviews cognitive research into socialcognition impairments and phenomenologicalresearch into self-disorder in psychotic disorders,before arguing that disturbance of the basic sense ofself (or ‘ipseity’ disturbance) may underlie the socialcognition difficulties apparent in schizophrenia andother psychotic disorders. Finally, we address theimplications of this theoretical model for earlyintervention efforts.

SOCIAL COGNITION IMPAIRMENTS INSCHIZOPHRENIA AND OTHER PSYCHOTICDISORDERS

From a cognitive psychology perspective, socialcognition refers to the domain of cognition thatinvolves the perception, interpretation and process-ing of social information.3 Previous research relatingto this concept (and with regard to psychosis) hasconcentrated on the three distinct areas withinsocial cognition of emotion perception, socialknowledge and social information processing.Social cognitive abilities tested have included affectrecognition, social perception, social knowledgeand causal attribution bias.4 Theory of mind (ToM),the cognitive capacity to represent another person’smental states, such as their thoughts, beliefs orintentions, has also been classified as a social-cognitive ability.5

Despite the immense attention it has received inrecent years, social cognition remains a somewhatill-defined and heterogeneous concept and is inneed of further validation.6 Nevertheless, a substan-tial body of evidence has accumulated for the pres-ence of social cognition deficits in patients withschizophrenia.4 For instance, specific emotion rec-ognition deficits (both for facial affective expressionand prosody), particularly with regards to fearand sadness, have been found in individuals withschizophrenia compared to affective psychoses andnon-patients, independent of intelligence.7,8 Othersocial cognition deficits include deficits decodingnon-verbal social cues,9 recognition of familiarsocial situations10 and interpersonal problemsolving.11 These social-cognitive deficits appear tobe present in the first episode of schizophrenia.7,12–14

Some evidence suggests that the healthy relatives ofpeople with schizophrenia also suffer some socialperceptual deficits.15,16 ToM and emotion recogni-tion difficulties are also present in individuals withschizotypal personalities,17,18 suggesting that suchsocial cognition deficits may be a trait as well asstate phenomenon. Furthermore, some findings

indicate that patients with schizophrenia have morepronounced impairments on social cognitive thancognitive tasks.19,20

Some theorists have argued that social cognitionmay be important in understanding the develop-ment of symptoms in schizophrenia. Frith21 pro-poses that impairments of meta-representation (asdemonstrated by poor performance on ToM tasks)might lead to symptoms such as delusions of refer-ence, paranoid delusions, incoherent speech andthird-person hallucinations, via a failure to repre-sent self and other awareness.22–24 There is goodempirical evidence that ToM is specifically impairedin schizophrenia5,25 but tasks that involve a moresophisticated higher order of ToM such as irony andmetaphor appear more likely to be impaired than‘first order’ tasks (the latter refers to identifying theliteral meaning of utterances rather than inferringintentions behind these utterances).26 In a differenttheoretical model, Bentall and colleagues hypoth-esize that distortion in the perception, interpreta-tion and attribution of social information underliethe positive symptoms of hallucinations and delu-sions.27 Although limited work has been conductedon identifying the particular neural system(s)responsible for execution of behaviours duringsocial-cognitive tasks, authors have suggested thatthe hypothesized neural substrates of social cogni-tion overlap with those implicated in the aetiologyof schizophrenia.4

It is possible that the poor social functioningobserved in schizophrenia (such as compromisedsocial relationships, social behaviours and socialactivities28–30) may be due at least in part to socialcognition difficulties. Studies have suggested thatindividuals with schizophrenia who perform poorlyon social cognition tasks also have poor socialfunctioning as evidenced by ward behaviour ormeasures of social skills.4,31,32 Poor functioning,including social functioning, is also present in‘ultra-high risk’ (UHR) populations and has beenfound to predict psychosis onset.33 More globally, forexample in the Israeli34 and Swedish35 draft studies,deficits in social cognition (e.g. an assessment ofsuitability to become an officer) were the bestpredictors of future schizophrenia.

Social cognition has not been directly assessed inUHR or prodromal patients (see above), but is thesubject of ongoing work by our research group. It ispossible that deficits in social cognition underlie thepoor social functioning observed in individuals atrisk of psychotic disorders and may even be theunderlying psychological deficit that incurs thisrisk. In this vein, Cornblatt and Keilp36 hypothesizethat impairments in social information processing

Self and social cognition in schizophrenia

84 © 2009 The AuthorsJournal compilation © 2009 Blackwell Publishing Asia Pty Ltd

may predict later social deficits in at-risk subjects.The only longitudinal study to address this possibil-ity has been conducted by Frenkel and colleagues37

in an Israeli high-risk cohort. They found that exter-nalized locus of control (a measure of attributionalstyle, suggested by some authors to utilize socialcognition skills38) was associated with the laterdevelopment of schizophrenia and major affectivedisorders in the cohort. The precise role of socialcognition deficits in at-risk populations remains tobe clarified, but the evidence reviewed above sug-gests that it may play a role in, or at least be an indexof, psychotic psychopathology.

SELF-DISTURBANCE IN SCHIZOPHRENIA ANDOTHER PSYCHOTIC DISORDERS

The notion of self-disturbance has received con-siderable attention in the phenomenological psy-chiatric tradition (see Nelson et al.39 for review).We will briefly review this research before arguingthat self-disturbance may underlie social cognitionimpairments.

Phenomenologically oriented researchers haveproposed that a disturbance of the basic sense ofself is a psychopathological trait marker of psychoticvulnerability, particularly of the schizophreniaspectrum.40–45 This formulation is based on a com-bination of empirical research, clinical experienceand phenomenological considerations. Since theearly twentieth century, anomalous self-experiencehas not played a central role in Anglo-Americanschizophrenia research, but has continued as afocus for phenomenological psychiatrists. Forinstance, Minkowski46 argued that the ‘troublegénérateur’ of schizophrenia was the self’s loss ofvital contact with reality (i.e. reduced sense of basic,dynamic and vital connection with the world; seealso Berze47 and Bleuler48). It has been argued thatself-disturbance is crucial for the cognitive and per-ceptual disturbances in schizophrenia,44 which havesuch a dramatic effect on practical and social abili-ties, and in particular on the characteristic distur-bance of common sense. For Blankenburg,49–51 thecentral defect in schizophrenia is a ‘loss of naturalself-evidence’ – that is, ‘loss of the usual common-sense orientation to reality, of the unquestionedsense of obviousness, and of the unproblematicbackground quality that normally enables a personto take for granted so many aspects of the socialand practical world’44 (p. 434). In more recent years,considerable empirical support has accumulatedfor the concept of self-disturbance as a phenotypicmarker of schizophrenia spectrum disorders

present during the prodromal phase, before theemergence of frank psychotic symptoms.52

In order to understand the type of self-disturbance being referred to in recent phenomeno-logical writings, it is necessary to distinguishbetween several ‘levels’ or types of selfhood.Parnas41 identifies three levels of selfhood from aphenomenological perspective (see also Parnas42).First, there is a prereflective level of selfhood, whichrefers to a first-person givenness of experience – the(implicit) awareness that this is ‘my’ experience.This is sometimes referred to as the ‘basic’ or‘minimal’ self or as ‘ipseity’ (see also Sales et al.44,Zahavi and Parnas53 and Zahavi54). Second, at amore explicit or complex level, we can speak of areflective self-awareness. This is an awareness of selfas an invariant and persisting subject of experienceand action – my sense of myself as the same personthrough time, for example. This level of selfhoodpresupposes the basic sense of self, because to havea sense of temporal unity, for instance, assumesknowledge that moment-to-moment experience ismine in the first place. Finally, there is the social ornarrative self. This refers to individual characteris-tics such as personality, habits, style and so on. Thephenomenological model of self-disturbance inschizophrenia spectrum disorders suggests that thedisorder of self occurs at the first or most basic levelof self-awareness (‘ipseity’), in contrast to the disor-dered self in non-schizophrenia spectrum personal-ity disorders, such as borderline or narcissisticpersonality disorder, in which the self is disturbedon the level of the social self, with a more basic senseof self remaining intact.52 There is empirical supportfor this difference in self-disturbance between diag-nostic groups from the Copenhagen ProdromalProject.55

The types of disturbance of self-experienceevident in the prodromal period include disturbedsense of presence, corporeality, stream of con-sciousness, self-demarcation and existential reori-entation, all of which are intimately interrelated.41,56

These phenomena have been describedelsewhere41,45,52,56–58 and will not be described indetail here. However, we will briefly outline thedisturbance of presence because it is importantfor the connection between disturbed selfhoodand social cognition.

Phenomenology proposes that our basic sense ofself and sense of immersion in the world areco-constituting and therefore inseparable.59 Normalhuman experience consists of being absorbed inactivity amongst a world of objects and this absorp-tion provides us with a sense of ‘inhabiting’ our selfin a prereflective, tacit or automatic fashion. This is

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referred to as presence. Our experiences appear to usin a first-person mode of presentation – that is, weautomatically or prereflectively experience them asour experience. This sense of ‘mineness’ constitutesa basic form of self-awareness. The sense of pres-ence or basic self-awareness is the backgroundupon which explicit, thematic or objectifyingconscious activity takes place. For instance, myawareness of what the person sitting next to me issaying to me takes place against the implicit back-ground that it is I who is aware of and listening tothis person speak – this is not something I question,it simply sits quietly in the background of aware-ness, providing me with a sense of ‘mineness’ toimmediate experience.

Studies have found that disturbance of presenceis the earliest and most fundamental feature of theschizophrenic prodrome.43,60 There is a characteris-tic sense that the self no longer ‘saturates experi-ence’ (52, p. 125), but is instead alienated from itself.This may appear in various forms, including: adiminished sense of basic self, such as sense ofinner void, lack of identity, being different fromothers, etc.; distorted first-person perspective, suchas decreased or temporally delayed sense of mine-ness to experience, pervasive sense of distancebetween the self and experience and spatializationof the self (varieties of depersonalization); adecreased ability to be affected by objects, people,events, states of affairs, as though the person isno longer fully participating or entirely present inthe world; derealization (an impression that thesurrounding world has somehow transformed, isunreal or is strange); intense reflectivity in the formof a tendency to take oneself or parts of oneself oraspects of the environment as objects of intensereflection, for example thinking about one’s ownthinking; loss of ‘common sense’ and perplexity,such that there is difficulty automatically graspingthe meaning of everyday events and the naturalnessof the world and other people is lacking.

The anomalies of self-experience noted above arenot yet of psychotic intensity. In the transition toa frank psychotic episode, these anomalies arestrengthened and thematized in the form of delu-sions, hallucinations and passivity phenomena. Theloss of presence or ‘mineness’ of experience, forinstance – which tends to involve hyperreflexiveawareness of aspects of thought and bodily experi-ence that would normally be experienced in a back-ground, implicit or non-focal manner – evolvesinto delusions of influence (see Parnas42, Sass andParnas44, Sass45 chapter 7, Parnas and Sass56 forillustration of the progression of these anomaliesto frank psychotic symptoms.)

The processes that are thought to underlie theanomalous self-experience described above are thecomplementary distortions of hyperreflexivity anddiminished self-presence.44,45 Hyperreflexivity is aform of exaggerated self-consciousness and height-ened awareness of aspects of one’s experience. Thisstyle of awareness objectifies aspects of oneself thatare normally tacit (e.g. awareness of the act ofbreathing or sensations while walking), therebyforcing them to be experienced as if they were exter-nal objects. The metaphor of a centrifuge is appro-priate: the hyperreflexive attitude spins aspects ofthe self outwards, until they form separated andestranged entities. It is important to note that hyper-reflexivity is a concept that includes hyperreflectiv-ity (that is, an exaggerated intellectual or reflectiveprocess) but is not limited to this: it also refers toacts of awareness that are not intellectual in nature,and that may not occur voluntarily, as in the case ofkinaesthetic experiences ‘popping’ into awareness.61

Diminished self-presence refers to a weakenedsense of existing as a subject of awareness. Sass andParnas44 consider hyperreflexivity and diminishedself-presence to be complementary aspects of‘disturbed ipseity’. They write: ‘. . . Whereas thenotion of hyperreflexivity emphasizes the way inwhich something normally tacit becomes focal andexplicit, the notion of diminished self-affectionemphasizes a complementary aspect of this verysame process – the fact that what once was tacitis no longer being inhabited as a medium of taken-for-granted selfhood’ (p. 430).

The role of a kind of hyperreflexivity (excessiveself-focused attention) in psychotic symptoms hasbeen confirmed by recent research in the cognitiveand cognitive-behavioural traditions (for a review,see Dr José M. Garcia-Montes et al., unpubl. data,2009). In a study of 30 schizophrenia patients withauditory hallucinations, Ensum and Morrison62

found that decreasing self-focused attentionreduced the external attributional bias associatedwith auditory hallucinations. In a related work,Perona et al.63 found heightened self-focused atten-tion to be associated with positive symptoms ingeneral. Morrison and Wells64 found meta-worry(worry about worrying, a kind of hyperreflexivity) tobe associated with strong emotional responses tohallucinations and also with negative symptoms.

SELF-DISTURBANCE AS UNDERLYING SOCIALCOGNITION IMPAIRMENTS

In terms of the relationship between self-disturbance and social cognition impairments, the



concepts of loss of ‘common sense’ and schizo-phrenic autism, both of which can be understood asexpressions of disturbed selfhood, are key. TheGerman psychopathologist Blankenburg49,50 wrotethat people with schizophrenia suffer from a ‘basicchange of existence’ in the structure of theirconsciousness, which leads to the loss of their abilityto grasp what is of day-to-day significance and theirability to be connected with others in a shared world.He referred to this as a ‘loss of common sense’,or normal sense of obviousness or natural self-evidence. Claiming that people with schizophreniahave lost their common sense is to say that they havelost their ability to take things ‘in the right light’,despite the fact that they may still retain their abilityto use logic and to engage in abstract discussions.65

Their ability to make interpretations and soundjudgements has been affected, making it difficult forthem to cope with daily practical and social activi-ties. The confusion or ‘perplexity’ (Ratlösigkeit66)that results from this loss of common-sense judg-ment (highly characteristic of schizophrenia) seemsto involve an absence of vital, motivating concerns(a concomitant of normal self-affection), and anemergence into awareness of what would normallyhave been too self-evident to be noticed (hyperre-flexivity, the other facet of ipseity-disturbance).44

The self-disturbance described here would alsoseem likely to mediate the type of difficulties thatcognitively-oriented researchers have referred to associal cognition and ToM deficits.

Parnas et al.67 note that the classic psychopa-thologists agreed that, diagnostically speaking, acertain characteristic Gestalt, irreducible to singlesymptoms or signs, distinguished the schizophreniaspectrum from other disorders. The terms used inthis context were ‘diagnosis through intuition’,68

‘atmospheric diagnosis’,69 ‘Praecox Gefühl’70 and‘diagnostic par penetration’.71 All these terms con-verge in pointing to an intersubjective nature of thisGestalt. This intersubjective quality is also reflectedin Bleuler’s48 concept of autism as the clinicalessence of schizophrenia, in the sense of a detach-ment from reality associated with a rich fantasy life.Minkowski46 extended Bleuler’s description byarguing that the fundamental disturbance (‘troublegénérateur’) in schizophrenia is a deficit in thebasic, non-reflective attunement between theperson and his world, that is a lack of ‘vital contactwith reality’. Minkowski defined the vital contact asan ability to ‘resonate with the world’, to empathizewith others, an ability to be affected and to act suit-ably. For this to occur, a prereflective immersion inan intersubjective world is necessary: ‘Withoutbeing ever able to formulate it, we know what we

have to do; and it is that which makes our activityinfinitely malleable and human’.72 Schizophrenicautism, according to Minkowski, involves a peculiardistortion of the relationship of the person tohimself, and of the person to the world and to otherpeople. There is a decline of the dynamic, flexibleand malleable aspects of these relations, and a cor-responding predominance of the fixed, static, ratio-nal and objectified elements. A famous vignette of aschizoid father who buys a coffin as a Christmaspresent for his dying daughter illustrates this oddfriction between act and context.67 The act is ratio-nal from a formal-logical point of view, because acoffin is something that the daughter is eventuallygoing to need, yet nevertheless it is bizarre by anyordinary human standard. Again, the notions of dis-turbed social cognition or ToM parallel this loss ofprereflective attunement to context or the socialworld.

In a similar vein, Parnas et al.67 maintain thatthere is a triadic disturbance of subjectivity at thecore of schizophrenia spectrum conditions. Theseinclude a unique disturbance of intentionality (e.g.loss of meaning and perplexity), a disturbance in therealm of self (an ‘unstable first-person perspective’and other anomalous self-experiences) and a fun-damental impairment in the dimension of inter-subjectivity (disorders of social and interpersonalfunctioning and inappropriate behaviour). Theyargue that these three dimensions are inseparable:I, we and the world belong together73,74 – and theyare all afflicted in the schizophrenia spectrum.The diminished self-presence or ‘ipseity’ describedabove has a reverberating effect through thesetriadic aspects of subjectivity. The world and otherpeople are no longer a stable background to ourexperience. These are no longer pregiven as tacitand unnoticed, as natural and familiar,45 asfamously captured in the words of Blankenburg’s49

patient Anne:

‘What is it that I really lack? Something so small,so comic, but so unique and important that youcannot live without it [. . .]. What I lack really is the“natural evidence” [. . .]. It has simply to do withliving, how to behave yourself in order not to bepushed outside society. But I cannot find the rightword for that which is lacking in me [. . .]. It is notknowledge, it is prior to knowledge; it is somethingthat every child is equipped with. It is these verysimple things a human being has the need for, tocarry on life, how to act, to be with other people,to know the rules of the game.’ [. . .]

Another patient writes to his friend:

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‘For your happiness, your lenience and your secu-rity, you can thank “a something” of which you arenot even conscious. This “something” is first of allthat which makes lenience possible. It providesthe first ground’. Quoted from Parnas et al.67

(p. 133)

As our shared engagement with the world (our‘common sense’ or ‘rules of the game’) is compro-mised, so is our prereflective attunement withothers.

These disturbances of subjectivity would natu-rally result in social cognition and ToM difficulties.The person has difficulty understanding the mentalstates and intentions of others because of a basicrupture of their self-presence, which forms theground of other- and world-directedness. A diffi-culty in intuiting others’ mental states and inten-tions is a corollary of a lack of shared engagementwith the world, which arises from a loss of self-presence. In a sense, the person relates to others(social cognition) as he stands in relation to himself:the self-alienation is paralleled in the alienation,distance and perplexity in relation to others. This isa sort of reverse process of the ‘praecox feeling’ (analienation or strangeness felt by others towards theschizophrenic person70), if one thinks of the ‘praecoxfeeling’ as an intuited recognition by others of theschizophrenic person’s alienated stance in relationto himself.45 The instability in self structure leads toawkward, ‘unnatural’ attempts to grapple with themeaning of others’ mental states and intentions.

It should be noted that it is not yet clear in the ToMliterature that ToM impairments in schizophreniaare due to deficits or lack of ‘mentalizing’. Certainly,ToM deficits, though perhaps present in schizophre-nia, do not seem to involve the kind of relativelystraightforward deficit condition found in childhoodautism. Research shows that schizophrenia patientsdo not, in fact, fail to mentalize (see McCabe et al.75

for a close study demonstrating the complex meta-levels present in clinical conversations with patientswith schizophrenia). Rather, they mentalize inabnormal ways: that is, they seem frequently to getthe perspective of the other wrong (often in ways thatflout common sense24,76,77) or even by projecting self-directed intentional states that are not present (thehypermentalizing often found in paranoid schizo-phrenia patients78,79). Some researchers have sug-gested that ToM may in fact be exaggerated inpsychotic conditions, in the sense of an over-attribution of mental states to self and other, a notionthat has been termed the ‘hyper-ToM’.80,81 Interest-ingly, this resembles the phenomenological conceptof hyperreflexivity described above (see Dr José M.

Garcia-Montes et al., unpubl. data, 2009 for furtherdiscussion of similarities between hyperreflexivityand recent cognitive research findings). Consistentwith this view is the observation that schizophrenicpatients, unlike autists, are prone to offer variouskinds of unconventional or erroneous responses onToM tests, rather than just those that suggest a failureto mentalize.82

The above discussion hints at the relationshipbetween disturbances of ipseity and of social cogni-tion, both so prominent in schizophrenia. Let usaddress this issue more directly: Is one of thesefactors especially likely to be the cause or source orthe other?* On theoretical grounds, it seems unlikelythat social disturbance would play the more funda-mental role: it is difficult to see how certain distur-bances prominent in the research on self-disorders– such as bodily/kinesthetic abnormalities (whichoften involve hyperreflexive awareness of sensa-tions that would not normally be in the focus ofawareness) – could result from disorders that arespecific to the domain of social cognition in particu-lar. It is true that many theorists have emphasizedthe essentially social nature of the sense of self (e.g.G. H. Mead,83 Vygotsky,84 Hermans et al.85). Thesetheorists have not, however, been thinking ofipseity, as defined in this article, but of less funda-mental aspects of selfhood that involve socialidentity or a sense of continuity over time.†

By contrast, it is easy to conceptualize the possibleimpact of ipseity disturbance on social cognition.Below we sketch three possible reasons or routes.

Dissimilarity

The first and most obvious reason concerns theradical discrepancy in the form of subjectivity of thetwo persons in question. The difference between asubject who has and one who lacks a modicum ofnormal ipseity is about as profound a discontinuityas can be imagined. Since the seventeenth century,Western philosophers have, in fact, been inclined toconsider normal ipseity – the essence of Descartes’cogito – to be a crucial sine qua non for the presenceof human subjectivity itself. Normal intersubjectiv-ity and empathy does not, of course, requirecomplete similarity between a knower or empa-thizer and the object of her (social) knowledge or

*It is also possible that they are in some kind of reciprocal inter-action, or even that they are complementary aspects of a singleabnormality.†An exception is Lacan86, who in his famous theory of the ‘mirrorstage’ appears to hold that a quasi-social, external sense of self isactually the source of deeper, inner feelings of coherence andcontrol.



empathy; still, it will benefit tremendously frombasic commonalities between the two. The personwith serious ipseity disturbance will therefore haveconsiderable difficulty in accurately conceiving theexperience or point of view of normal individualswhose experience is imbued with this dimension.He will be seriously compromised in intuitivelygrasping the dynamically shifting perspectival websthat characterize normal intersubjectivity, due to hisown disturbed ipseity. The influence of this ‘dissimi-larity’ may also extend to the emotion recognitiondifficulties and attributional styles in schizophrenia,as described above.

The second and third reasons concern ways inwhich ipseity disturbance would be likely to disruptpsychological processes that mediate normalhuman understanding.

Disruption of lived body

Some of the above-mentioned processes, especiallyprominent in face-to-face interaction, have a strongbodily and affective/emotional nature, involvingcomplex and largely unconscious ways in which oneresonates on a corporeal level (and in ways bothcomplementary and symmetrical) with the bodyand movements of the other person with whom oneinteracts. (Successful interactions between mothersand infants provide the most carefully studied, andperhaps archetypal, of these forms.87–89) But ipseitydisturbances typically involve forms of bodily alien-ation and awkwardness in which normally tacitbodily experiences become objects of focal atten-tion, and can, therefore, no longer serve as a fluidmedium by means of which a person can spontane-ously resonate with, and thereby attend to andgrasp, the being and attitudes of the other person.

Disturbed mental coherence

The third reason concerns the relatively uninte-grated nature of thought and perception in personswith ipseity disturbance, and the special relevancethis may bring for specifically interpersonal cogni-tion because of what has been called the ‘holism ofthe mental’. One of the most widely accepted ideasin current philosophy of mind and cognitivescience is the notion that coherence is especiallyrelevant to the knowledge of other minds becausethe very possibility of attributing intentional states(beliefs and desires) relies on the possibility of con-sidering these states to hang together in somecoherent or mutually supportive fashion. The ideais that a kind of holism is essential for mental attri-butions, namely, that a particular mental or inten-

tional state having propositional content (‘I want x’;‘I believe y’) can only be considered meaningful ifit exists in coherent or rational relationship to a setof other occurrent intentional and dispositionalstates, and that, in the absence of such coherence,one simply could not attribute any meaning at all.90

(Another way of putting this point is to say that theinterpretive or hermeneutic ‘principle of charity’is a constitutive feature for the attribution ofmeaning.) It is significant, then, that ipseity distur-bances will typically involve or result in a decline inthe overall meaningful coherence of the patient’smental life – both because diminished self-presence implies an absence or decline of the sortof animating ‘concern’ or ‘care’ that forges unity inthe experiential field, and also because hyperreflex-ive awareness has an inherently alienating and frag-menting effect (e.g. by tending to isolate singlethoughts or parts of thoughts). A person whose ownexperience and modes of thought are less imbuedwith coherence, is also less likely to discover orimagine coherence when encountering an Other;for just that reason, he may be less likely to attributefully coherent mental states, or even, at times, toattribute mental states at all.

The three points just mentioned can be con-sidered in relationship to the theories of so-called‘mentalizing’ or ‘mind-reading’ (also known as‘ToM’) that are currently prominent in psychologyand cognitive science: namely, Simulation Theory(e.g. Goldman91) and Theory Theory (e.g. Perner92).(There are also hybrid theories that synthesize thetwo (e.g. Stich and Nichols93).) According to theSimulation Theory, mentalizing largely involvesempathic processes, what Goldman91 (p. 4) calls a‘putting oneself in others’ shoes’ whereby one repli-cates or emulates by ‘generat[ing] mental states thatmatch, or resonate with, states of people one isobserving’. The first two factors mentioned above –dissimilarity and disruption of the lived and affec-tive body – would seem likely to preclude or disruptthe creation of such matching simulations. Accord-ing to Theory Theory, mentalizing is not fundamen-tally different, in form, from the kind of theoreticalexplanation pursued in the natural sciences: it isbasically a matter of using inferential processes, inline with a naïve psychological theory, to hypoth-esize what the other person thinks or feels. The thirdfactor mentioned above – disturbed coherence –would seem especially likely to disrupt theseprocesses of holistic intellectual hypothesizing.

It seems, then, that on theoretical grounds, thereis good reason to suspect that, in schizophrenia, thedisturbance of ipseity would be a more basic orpathogenetically primordial process than are the

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disturbances in social cognition.‡ There may alsopossibly be a shared neural substrate to ipseity andsocial cognition, which further strengthens thepathogenetic link between the two. This issue will beaddressed in a future paper.§

CONCLUSIONS AND FUTURE DIRECTIONS

This paper outlined the areas of social cognitionimpairments in psychotic disorders, as detailed incognitive research in psychotic disorders and self-disturbance, as articulated in phenomenologicalresearch in psychotic disorders. We argued that dis-turbance of the basic sense of self (or ‘ipseity’ dis-turbance), which phenomenological theorists haveproposed as a core marker of the schizophrenicspectrum, may underlie the social cognition diffi-culties that are apparent in schizophrenia and otherpsychotic disorders. This argument was based onphenomenological thinking about self-presencebeing the primary or most basic ground for theintentionality of consciousness – that is, the direct-edness of consciousness towards others and theworld. A disruption in this basic ground of con-scious life has a reverberating effect through otherareas of cognitive and social functioning. We pro-posed three routes whereby self-disturbance maycompromise social cognition, including dissimilar-ity, disruption of lived body and disturbed mentalcoherence. If this model is supported, then socialcognition difficulties may be thought of as a second-ary index or marker of the more primary distur-bance of self in psychotic disorders.

‘Psychosis’ is of course a broader construct thanthe particular condition of ‘schizophrenia’, whichhas been characterized by classical psychopatholo-gists as involving a basic alteration of self-structure

and world experience independent of the manifes-tation of frank positive psychotic symptoms (seediscussion above). Both self (‘ipseity’)-disturbanceand social cognition deficits have been found toparticularly characterize the schizophrenia spec-trum, rather than be bound to psychotic disordersor positive psychotic symptoms generally, whichsupports the model proposed in this paper.

As stated at the outset, this is essentially a specu-lative and exploratory effort. Further theoretical andempirical work is required to extend and test theideas proposed in this paper. In terms of empiricalwork, this may be achieved by combiningsocial cognition and self-disturbance measures inresearch with clinical populations (a researchproject by our group will examine the correlationand predictive utility of these measures in aUHR sample). The recent introduction of a self-disturbance scale with good psychometric proper-ties, the Examination of Anomalous Self-Experience(EASE; Parnas et al.58), provides an opportunity forthis type of work to be conducted. To date, the EASEhas demonstrated good to excellent interrater reli-ability, with single-item kappa values ranging from0.6 to 1.0.58 Extending this line of research mayclarify key pathogenic factors associated with onsetof schizophrenia and other psychotic disorders andthereby suggest specific avenues for interventionstrategies in early psychosis.

Developing models that integrate different areasof psychosis research, as in the current paper,is critical if coherent, comprehensive models ofschizophrenia and other psychotic disorders are tobe developed. Although the current paper focusedon cognitive and phenomenological research,this can be extended to include other researchapproaches, including neurobiological research(see Pinkham et al.2). Without such integrativeefforts, psychosis research runs the danger of livingout the fable of blind men touching different partsof the elephant and deriving distorted pictures ofthe whole from what they know (one group seesthe elephant as being like a snake, the other like awall, etc.).

It is important to investigate the cognitive andphenomenological concepts discussed above inearly psychosis populations, including pre-onset orUHR populations, in order to examine the poten-tial predictive validity and reliability of these vari-ables. Although social cognition deficits in UHR orprodromal samples are in need of further directinvestigation, there is good restrospective evidencefor the existence of self-disturbance in this group.39

It is possible that disturbance of social cognitionand self-experience may function as a means of

‡Some writers in the continental phenomenological tradition54,94

argue for a more intimate complementarity between basicself-experience and experience of the other – between ipseity andalterity. From this standpoint, there might even be somethingmisleading in posing the question as to the relative primacy ofsocial cognition versus ipseity, since the two phenomena are sofundamentally intertwined. This is not the place to discuss thiscomplex but appealing hypothesis. Here we simply note thatthese authors’ conception of alterity bears little resemblance tothe notions of social cognition that are characteristic of currentcognitive science.§Although this section has focused on points of intersectionbetween cognitivism and phenomenology, we note that there areprofound philosophical differences between the two and that,historically speaking, many phenomenologists have seen theirperspective in opposition to the assumptions of cognitive psy-chology (see 56,95,96 and Dr José M. Garcia-Montes et al., unpubl.data, 2009). Addressing this issue, however, is beyond the scopeof the paper.



further ‘narrowing down’ on true positives (i.e.individuals who are truly prodromal or on the pathto developing frank psychosis) within the UHRpopulation.39 This is important not only due toethical concerns about treating false positive UHRpatients with treatments specifically designed todelay or prevent psychosis onset,97,98 a salientconcern given recently observed decliningtransition rates within UHR populations,99 but alsobecause it sheds light on the conceptual and con-struct validity of schizophrenia and other psychoticdisorders, their essential psychopathological fea-tures, and phenotypic boundaries.100

ACKNOWLEDGEMENT

BN was supported by a Ronald Phillip Griffith Fel-lowship and a NARSAD Young Investigator Award.The authors also acknowledge the support of theColonial Foundation.

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