Brief Report

Not all first-episode psychosis is the same:preliminary evidence of greater basic

self-disturbance in schizophrenia spectrum casesBarnaby Nelson,1 Andrew Thompson2 and Alison R. Yung1

1Orygen Youth Health Research Centre,Centre for Youth Mental Health,University of Melbourne, Melbourne,Victoria, Australia; and 2East Sussex EarlyIntervention in Psychosis Service andDepartment of Psychiatry, Eastbourne, UK

Corresponding author: Dr BarnabyNelson, Orygen Youth Health ResearchCentre, University of Melbourne, 35Poplar Road (Locked Bag 10), Parkville,Vic. 3052, Australia. Email: nelsonb@unimelb.edu.au

Received 28 February 2012; accepted 16April 2012

Abstract

Aim: Disturbance in the basic sense ofself has previously been found tocharacterize schizophrenia spectrumdisorders and to predict onset of psy-chosis in the ultra-high-risk popula-tion. The current study examinedbasic self-disturbance in a first-episode psychosis (FEP) population.We hypothesized that basic self-disturbance would be more promi-nent in cases with a schizophreniaspectrum disorder compared to thosewith other psychoses.

Method: Sixteen FEP patients fromOrygen Youth Health, Melbourne,were recruited to the study. Part-icipants were assessed using the

Examination of Anomalous Self-Experience and the Structured Clini-cal Interview for DSM-IV.

Results: Basic self-disturbance scoreswere significantly higher in patientswith a schizophrenia spectrum diag-nosis (n = 8) compared to patientswith other psychotic diagnoses(n = 8).

Conclusions: The findings are consis-tent with previous work indicatingthat the disturbance of the basic senseof self is more characteristic of schizo-phrenia spectrum psychosis thanother psychoses. This may have impli-cations for early diagnosis, clinicalformulation and intervention.

Key words: early intervention, psychosis, schizophrenia, self.

INTRODUCTION

Phenomenologically oriented researchers haveproposed that a disturbance of the basic sense ofself is a ‘core’ feature of schizophrenia spectrumpathology.1–5 This formulation is based on a combi-nation of empirical research and philosophicalconsiderations,1–3,6–9 emerging from phenomeno-logically oriented clinical observations and explora-tion.7,10 The ‘basic’ self is a pre-reflective, tacit level ofselfhood. It derives from the ‘given’ fact that all expe-rience has a first-person quality, that there is animplicit ‘ownership’ of experience or awareness thatthis is ‘my’ experience. The term ‘basic’ or ‘minimal’self reflects the notion that this level of selfhood isthe ground on which various aspects of consciousexperience occur. This is in contrast to more elabo-rated levels of selfhood, such as the reflective self(the self as an object of reflection) or the narrativeself (social identity).2 The subjective anomalies of

experience (e.g. disturbed stream of consciousness,sense of presence, bodily experience, self-demarcation and existential reorientation2,9) thatarise from basic self-disturbance become progres-sively more articulated and thematized as psychoticsymptoms develop, crystallizing in the form of delu-sions, hallucinations and passivity phenomena.8

Early descriptions of schizophrenia includedanomalous subjective experience, including pro-found transformations of the self, as intrinsic to thedisorder. Indeed, such disturbances were thought toanchor the phenotypic validity of the schizophreniaspectrum concept.11 A recent series of empiricalstudies has yielding data consistent with thisview.3,11,12 In two studies, a Danish research groupfound that self-disturbance is specific to schizo-phrenia spectrum conditions compared with remit-ted psychotic bipolar patients, and a mixed group offirst-admitted patients is characteristic of pre-schizophrenic prodromes and frequently occurs in

Early Intervention in Psychiatry 2012; ••: ••–•• doi:10.1111/j.1751-7893.2012.00381.x

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hospitalized schizotypal conditions.2,13–15 Self-disturbance aggregated significantly in patientswith a positive family history of schizophrenia. In5-year follow-up data of 155 first-admission cases,self-disturbance emerged as a strong predictor of afuture schizophrenia spectrum diagnosis in thosepresenting with non-psychotic conditions (oddsratio = 12, 95% confidence interval 2.15–67.0716).Genetic linkage data have indicated a similarpattern of findings. Raballo and Parnas17 analysedthe data from 218 unaffected members of sixextended families assessed during the CopenhagenSchizophrenia Linkage Study.18 Self-disturbancewas incrementally present in groupings of familymembers with no mental illness, no mental illnessbut with schizotypal traits, personality disordersother than schizotypal personality disorder (themajority of whom had comorbid schizotypal traits),and schizotypal personality disorder, independentof sociodemographics, negative symptoms andformal thought disorder. Similar findings wereevident when this dataset was analysed according toschizophrenia spectrum conditions, with self-disturbance being characteristic of schizophreniaspectrum conditions and levels of self-disturbanceincreasing with diagnostic severity (no mentalillness, mental illness not in the schizophrenia spec-trum, schizotypal personality disorder, schizophre-nia).19 A recent study from our group indicated thatbasic self-disturbance predicts transition to psy-chotic disorder in the ultra-high-risk (UHR) popula-tion and is particularly prominent in schizophreniaspectrum conditions (UHR patients with a schizo-typal personality disorder or who transition to aschizophrenia spectrum psychosis).20

The aim of the current study was to assesswhether basic self-disturbance is more prominentin first-episode psychosis (FEP) patients withschizophrenia spectrum diagnoses compared withFEP patients with other psychotic disorders. Wehypothesized that the former group would displayhigher basic self-disturbance scores than the lattergroup.

METHOD

Setting and sample

OrygenYouth Health (OYH) is a public mental healthservice for young people aged between 15 and25 years living in northwestern metropolitan Mel-bourne, Australia. Participants were recruited fromthe Early Psychosis Prevention and InterventionCentre (EPPIC) continuing care team, whichprovides treatment for patients with FEP. Referrals to

OYH are accepted from a range of sources, includinggeneral practitioners and other primary care ser-vices, educational support services, drug andalcohol services, carers, families and young peoplethemselves. A central Triage service takes all referralsand refers to the appropriate clinic based on clinicaljudgement and semistructured clinical interviews.Inclusion criteria consisted of daily frank positivepsychotic symptoms for longer than a week. Exclu-sion criteria consisted of an organic cause of theclinical presentation, presence of an intellectual dis-ability (IQ < 70), as documented in the individual’smedical history, and lack of proficiency in English.The sample was recruited between May 2008 andMay 2010. The study was approved by the localresearch and ethics committee.

Measures

Demographics

Demographic information was collected via aninterviewer-administered questionnaire. Informa-tion was collected on: age, gender, marital status,country of birth, main language spoken, employ-ment, education, history of psychiatric treatmentand family history of psychiatric disorder. Durationof symptoms prior to clinic entry was also recorded.

Self-disturbance

Self-disturbance was assessed using the Examina-tion of Anomalous Self-Experience (EASE).9 TheEASE is a symptom checklist for semistructured,phenomenological exploration of subjectiveanomalies representative of basic self-disturbance.It consists of 57 items in 5 domains, which are notmutually exclusive: (i) cognition and stream of con-sciousness (17 items); (ii) self-awareness and pres-ence (18 items); (iii) bodily experiences (9 items);(iv) demarcation/transitivism (5 items); and (v) exis-tential reorientation (8 items). Symptoms can berated both dichotomously, that is, as present orabsent, or continuously on a 5-point (0–4) severity/frequency scale. The EASE has been found to havegood to excellent internal consistency (Cronbach’salpha above 0.87) and an overall interrater correla-tion above 0.80 (Spearman’s rho, P < 0.001).21

DSM-IV diagnoses

DSM-IV diagnoses were established using the Struc-tured Clinical Interview for DSM-IV,22 a structuredinterview based on the DSM-IV. The full axis Iinstrument was used.

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Procedure

Participants were assessed: (i) within the first6 months of treatment at EPPIC; and (ii) when theirsymptoms had stabilized (i.e. when they were notacutely unwell).

Statistical analysis

Independent sample t-tests were used to compareEASE scores between participants with a schizo-phrenia spectrum diagnosis (schizophrenia, schizo-phreniform disorder, schizoaffective disorder) andparticipants with other psychoses (mood disorderwith psychotic features, bipolar disorder with psy-chotic features, psychotic disorder not otherwisespecified (NOS), etc.). The analysis was conductedwith both continuous and dichotomous EASEscores.

RESULTS

Demographics and clinical features

Sixteen FEP participants were recruited. Sampledemographics and clinical features are presentedin Table 1. There were no differences on these

variables between patients with schizophreniaspectrum diagnoses compared to those with otherdiagnoses (see below), apart from the former groupbeing in less employment or education than thelatter group.

Diagnoses

The sample consisted of eight cases with schizo-phrenia spectrum diagnoses (schizophrenia = 5,schizophreniform disorder = 2, schizoaffectivedisorder = 1) and eight cases with other psychoticdiagnoses (psychotic disorder NOS = 5, mooddisorder with psychotic features = 1, bipolar disor-der with psychotic features = 1, substance-inducedpsychotic disorder = 1).

Self-disturbance

The EASE scores are presented in Table 2. Partici-pants with a schizophrenia spectrum diagnosishad significantly higher scores on the EASE totalscore and the Self-Awareness and Presence, BodilyExperiences and Demarcation/Transitivism EASEdomains. The same results were obtained withcontinuous and dichotomous EASE scores.

TABLE 1. Sample demographics and clinical features

Whole sample(n = 16)

Schizophreniaspectrum (n = 8)

Other psychoses(n = 8)

P-values*

Mean age (years) 21.63 (SD = 3.7) 22.25 (SD = 4.23) 21.00 (3.30) 0.52Gender 0.61

Male 10 (62.5%) 4 (50%) 6 (75%)Female 6 (37.5%) 4 (50%) 2 (25%)

Country of birth 0.37Australia 14 (87.5%) 7 (87.5%) 7 (87.5%)Other 2 (12.6%) 1 (12.5%) 1 (12.5%)

English as main language spoken N/AEnglish 16 (100%) 8 (100%) 8 (100%)Other 0 (0%) 0 (0%) 0 (0%)

Currently employed or studying 0.04Yes 7 (43.8%) 1 (12.5%) 6 (75%)No 9 (56.25%) 7 (87.5%) 2 (25%)

Marital status N/AMarried 0 (0%) 0 (100%) 0 (100%)Single 16 (100%) 8 (100%) 8 (100%)

History of psychiatric treatment 1.0Yes 15 (93.8%) 7 (87.5%) 8 (100%)No 1 (6.3%) 1 (12.5%) 0 (0%)

Family history of psychiatric disorder 0.61Yes 6 (37.5%) 4 (50%) 2 (25%)No 10 (62.5%) 4 (50%) 6 (75%)

Duration of psychotic symptoms (months) 3.06 (SD = 1.77) 3.50 (SD = 2.33) 2.63 (SD = 0.92) 0.34

*P-values refer to comparisons between the schizophrenia spectrum group and the other psychoses group.N/A, no significance statistics computed because variable is constant; SD, standard deviation.

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DISCUSSION

The current data indicate that disturbances of thebasic sense of self, as described in phenomenologi-cal psychiatric literature, are more pronounced inFEP patients with a schizophrenia spectrum psy-chosis compared with FEP patients with other psy-choses, confirming our hypothesis. Although thelatter group displayed some self-disturbances (withscores similar to those seen in an ultra-high-risksample20), they were not as pronounced as in theformer group. These data are consistent with previ-ous findings15,16 and support the view that there aresubtle but important differences in the subjectiveexperience of a schizophrenia spectrum psychosiscompared to other psychoses. The former may becharacterized more by disturbances in the stream ofconsciousness (cognitive disturbances), sense ofpresencein the social world and ‘ownership’ of experience,the tacit ‘habitation’ of the body, self-other andself-world boundaries, and existential orientation(for detailed description see1,3). Recent research,informed by the continuum model of psychosis,23

has argued for an extensive overlap in the clinicalpresentation and aetiopathophysiology of psycho-sis across different disorders.24 However, thesestudies have focused on cognitive impairments,neurobiological variables, candidate genes, andrelatively crude symptom measures, and havetended to ignore anomalies of subjective experienceacross the disorders.

Clearly, a limitation of the current study is thesmall sample size. The finding needs to be repli-cated in a larger sample in order to discount thepossibility of a type I error (a false positive result).However, the fact that significant findings emergedin such a small sample may indicate the strength ofthe difference in basic self-disturbance between

FEP patients with a schizophrenia spectrum psy-chosis compared to those with other psychoses.

The current finding does not mitigate the impor-tance of maintaining clinical and research attentionon the relatively broad category of FEP. However, itdoes suggest different points of orientation inunderstanding the shifts in subjective experienceassociated with an emerging schizophrenia spec-trum disorder compared with other psychoses,which may be useful clinically (in terms of case for-mulation and treatment targets) and in informingresearch questions.

ACKNOWLEDGEMENTS

BN was supported by a Ronald Philip Griffith Fel-lowship and a NARSAD Young Investigator Award.AY was supported by a National Health and MedicalResearch Council (NHMRC) Senior ResearchFellowship and the Colonial Foundation.

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TABLE 2. EASE scores in FEP patients with schizophrenia spectrum diagnoses compared to FEP patients with other psychotic diagnoses

EASE domain Schizophrenia spectrum (n = 8) Other psychoses (n = 8) P-values

Mean (SD) Mean (SD)

Continuous Dichotomous Continuous Dichotomous Continuous Dichotomous

Cognition and stream of consciousness 24.13 (16.43) 7.50 (4.63) 14.13 (6.51) 4.50 (3.21) 0.13 0.15Self-awareness and presence 27.13 (15.75) 8.38 (4.31) 11 (7.31) 3.25 (2.60) 0.02 0.01Bodily experiences 8.13 (7.14) 2.00 (1.93) 1.38 (2.77) 0.34 (7.44) 0.03 0.04Demarcation/transitivism 3.88 (2.47) 1.63 (1.51) 1.13 (1.13) 0.38 (0.52) 0.01 0.04Existential reorientation 10.25 (7.63) 3.63 (2.62) 6.00 (5.26) 1.75 (1.67) 0.22 0.11Total score 73.50 (46.22) 22.50 (12.98) 33.63 (17.48) 10.25 (7.15) 0.04 0.04

Continuous: EASE continuous scores. Dichotomous: EASE dichotomous scores.EASE, Examination of Anomalous Self-Experience; FEP, first-episode psychosis; SD, standard deviation.

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