ArticlePDF AvailableLiterature Review

EASE-scale (Examination of Anomalous Self-Experience)

Authors:
  • Vestre Viken Hospital Trust, Division of Mental Health and Addiction

Abstract

The Examination of Anomalous Self-Experience ( EASE) is a symptom checklist for semi-structured, phenomenological exploration of experiential or subjective anomalies that may be considered as disorders of basic or 'minimal' self-awareness. The EASE is developed on the basis of self-descriptions obtained from patients suffering from schizophrenia spectrum disorders. The scale has a strong descriptive, diagnostic, and differential diagnostic relevance for disorders within the schizophrenia spectrum. This version contains interview-specific issues and psychopathological item descriptions ( Manual), a scoring sheet ( Appendix A), a reminder list of items for use during the interview ( Appendix B) and an EASE/BSABS ('Bonner Skala fur die Beurteilung von Basis-symptomen') item comparison list (Appendix C).
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Manual
Psychopathology 2005;38:236–258
DOI: 10.1159/000088441
EASE: Examination of Anomalous
Self-Experience
Josef Parnas
a, d
Paul Møller
b
Tilo Kircher
c
Jørgen Thalbitzer
a
Lennart Jansson
a
Peter Handest
a
Dan Zahavi
d
a
Department of Psychiatry, Hvidovre Hospital,
University of Copenhagen, Copenhagen , Denmark;
b
Unit for Mental Health Research and Development, Division of Psychiatry, Buskerud Hospital, Lier , Norway;
c
Department of Psychiatry, University of Aachen, Aachen , Germany;
d
D
anish National Research Foundation,
Center for Subjectivity Research, University of Copenhagen, Copenhagen, Denmark
for a detailed account of phenomena that have in com-
mon a somehow deformed sense of fi rst-person perspec-
tive – in brief, a disorder or defi ciency in the sense of be-
ing a subject, a self-coinciding center of action, thought,
and experience
1
.
The scale is mainly designed for conditions in the
schizophrenia spectrum, but it cannot be used alone as a
diagnostic instrument (self-disorders are not listed by the
DSM-IV or ICD-10 as diagnostically crucial or even im-
portant features of schizophrenia; derealization and de-
personalization are mentioned as nonessential features of
schizotypy). The EASE does not cover all potential anom-
alies of experience, but focuses only on the disorders of
the self [in contrast to the BSABS (‘Bonner Skala für die
Beurteilung von Basissymptomen’) [Gross et al., 1987],
e.g. perceptual disorders are not explored].
Development of the EASE
The development of the EASE was originally moti-
vated by the clinical work in a day and stationary care
unit for patients with fi rst admission to the University
Department of Psychiatry of Hvidovre Hospital (over a
4-year period, approximately a total of 100 consecutive
The Examination of Anomalous Self-Experience
(EASE) is a symptom checklist for semi-structured, phe-
nomenological exploration of experiential or subjective
anomalies that may be considered as disorders of basic
or ‘minimal’ self-awareness. The EASE is developed on
the basis of self-descriptions obtained from patients suf-
fering from schizophrenia spectrum disorders. The scale
has a strong descriptive, diagnostic, and differential diag-
nostic relevance for disorders within the schizophrenia
spectrum. This version contains interview-specifi c issues
and psychopathological item descriptions (Manual), a
scoring sheet (Appendix A), a reminder list of items for
use during the interview (Appendix B) and an EASE/
BSABS (‘Bonner Skala für die Beurteilung von Basis-
symptomen’) item comparison list (Appendix C).
Introduction
Terms and concepts are explained under each section
and item.
Goals and Target Populations
The EASE focuses on anomalies of subjective experi-
ence that appear to refl ect disorders of self-awareness.
This scale is phenomenologically descriptive and the pur-
pose of description is predominantly qualitative, striving
Received: January 12, 2005
Accepted: April 26, 2005
Published online: September 20, 2005
Dr. med. Josef Parnas, MD
Department of Psychiatry, Hvidovre Hospital
University of Copenhagen
DK–2650 Hvidovre (Denmark)
E-Mail jpa@cfs.ku.dk
© 2005 S. Karger AG, Basel
0254–4962/05/0385–0236$22.00/0
Accessible online at:
www.karger.com/psp
1
There is, however, a possibility of rating frequency and intensity of anoma-
lous experience.
Examination of Anomalous
Self-Experience
Psychopathology 2005;38:236–258
237
patients were interviewed by J.P. and L.J.). The main
purpose was to explore and better comprehend the expe-
riential and behavioral manifestations of schizophrenic
autism [Parnas and Bovet, 1991]. A striking observation
was made that the majority of the patients uniformly re-
ported a long-time persisting identity void or more re-
cently occurring feelings of self-transformation. Two in-
dependent, uncontrolled studies conducted almost si-
multaneously in Denmark and Norway confi rmed these
impressions in a systematic way [Parnas et al., 1998;
Møller and Husby, 2000]. A recent study with 151 fi rst-
admission consecutive patients with various diagnoses
demonstrated that disorders of the self constitute impor-
tant aspects of schizophrenia and of schizotypy [Parnas
and Handest, 2003; Handest and Parnas, 2005]. Another,
separate study showed that self-disorders (recorded on a
lifetime basis) distinguish between residual schizophre-
nia and psychotic bipolar illness in remission [Parnas et
al., 2003]. The most recent analyses show that self-disor-
ders also aggregate among the schizophrenia spectrum
cases (schizophrenia and schizotypy) identifi ed in an ex-
tended genetic family study [Parnas et al., in prepara-
tion]. To summarize, the origin of the EASE was to a large
extent clinical phenomenological, based on many inter-
views with incipient schizophrenia spectrum patients,
and subsequently extended by systematically collected
empirical data from various samples cited above.
We were also inspired and informed by the classic psy-
chopathological descriptions of these subtle pathological
phenomena – e.g. in the work of Pierre Janet, Hans Gruh-
le, Joseph Berze, Eugène Minkowski, and Wolfgang Blan-
kenburg. We owe much inspiration to the German re-
search group of Gerd Huber, Gisela Gross, Joachim
Klosterkötter, Frauke Schultze-Lutter, and their col-
leagues, who were the few modern psychiatric scientists
who took the patient’s subjective experience seriously
and studied it in systematic ways. We were familiar with
Huber’s notion of ‘basic symptoms’ since the late 1980s,
and the BSABS became fully translated and published in
Danish in 1995. There are some natural overlaps with the
BSABS, especially in the domains targeting cognitive dis-
orders, cenesthesias and other single items. In these cases,
the original BSABS item numbers are given in parenthe-
ses after the item name. However, it is important to scru-
tinize the defi nitions carefully, because they are usually
not completely identical. Our own clinical psychopatho-
logical approach is very much informed by the Husser-
lian approach to phenomenology [Parnas and Zahavi,
2002; Sass and Parnas, 2003].
General Guidelines for Conducting the
Interview
Intrinsic Diffi culties of the Interview
The experiences that are targeted here are often so
strange to the patient that he has never communicated
them to anyone else. Often, they have not been men-
tioned to even closest confi dants. The experiences may
be eeting, perhaps even verging on something ineffable.
They are not like material objects that one can ‘take out
of one’s head’ and describe them as if they were things
with certain properties, or redescribe the experience at
different occasions in exactly the same terms. The patient
may be short of words to express his own experiencing.
One reason for this is that many of these experiences pos-
sess a prerefl ective quality. They are not explicit in the
focus of thematic attention but constitute more the over-
all background of awareness. Moreover, a patient may at
one occasion succeed to describe his anomalous experi-
ence with a pertinently salient metaphor, which will
somehow no longer be available to him at later occasions;
consequently, at these later occasions, he will only give
vague descriptions ( NB: We have no systematic empirical
information on these issues). The patient’s predicament
may be comparable to trying to describe his global pro-
prioceptive state. In addition, the distortions of self-
awareness undermine the patient’s capacity for self-ex-
pression. As already mentioned, many patients consider
their experiences as being uniquely private (i.e., in con-
trast to auditory hallucinations, regarded as a common
knowledge), and therefore the patients see these experi-
ences as embarrassing, ‘inhuman’ or deeply disturbing.
Use of Metaphor
The patients employ metaphors to describe what they
experience; this is also the case with healthy people – it is
a universal process. A metaphor is usually defi ned as a
transfer of meaning from one conceptual domain to an-
other, like in the expression: ‘life is a journey’ (the concept
of life is made meaningful by an appeal to a journey, be-
longing to another domain). In the context of a psychiat-
ric interview, a metaphor should not be seen as ‘just a
metaphor’ or ‘just a manner of speaking’ that somehow,
distortingly or conventionally, stands for
an underlying
(more) true or authentic anomalous experience, i.e., a
metaphor is not only a signifi er (sign), distinct from, and
contingently attached to the signifi ed content (‘signifi é’ =
the sign’s meaning). Rather the following is the case: an
experience (non- or prelinguistic), especially of the prere-
ective type, becomes progressively conceptualized, i.e.
Parnas /Møller /Kircher /Thalbitzer/
Jansson/Handest/Zahavi
Psychopathology 2005;38:236–258
238
transformed into a conceptual (linguistic) format, in or-
der to be grasped by the refl ecting subject, thematized and
rendered communicable to others. The metaphor should
be seen here as a basic functional aspect of this symbol-
ization process, where it operates as a linguistic vehicle
or medium through which the experience fi rst articulates
itself and so becomes refl ectively accessible. The meta-
phor is therefore the fi rst stage of making a prelinguistic
or prerefl ective experience explicitly accessible to oneself
and to the other. The choice of metaphor is linked to the
nature of experience in a noncontingent way, i.e., experi-
ence and metaphor are not entirely independent.
Necessities
To transmit the type of experience investigated here
to another person requires a certain intimacy between the
interviewer and the patient, and a need on the part of the
patient to make an effort in order to explore his own mind
or to refl ect upon his own experience. It is therefore man-
datory to try to establish a neutral, yet caring rapport with
the patient, and ideally to provide the patient with the
possibility to act as a partner in a shared, mutually inter-
active exploration. No matter how uncommon or bizarre
the reported experiences may seem to the interviewer, he
must remain neutral, calm, yet with a restrained inter-
ested caring attitude, and tacitly conveying to the patient
that he is familiar with the type of psychopathology under
investigation (it has usually a strongly positive impact on
the rapport). The interviewer should never adopt a curi-
ous/voyeuristic posture (in which the patient fi nds him-
self as a specimen of pathology) or a judgmental/valuing
attitude. What is being talked about is how the patient
experiences himself and his world, and not an objective-
ly or medically prescribed ‘reality’ or ‘morbidity’ of these
experiences. From the patient’s perspective, they are just
his experiences and are therefore indisputably real for
him as experiences (but not necessarily accompanied by
specifi c explicit beliefs about their causes or nature; see
‘as if’ experiential mode).
Hostile, aggressive, very suspicious patients or pa-
tients marked by severe emotional indifference require
an extraordinary effort from the interviewer to circum-
vent dissimulation or guardedness and engage the patient
in the interview. Acutely ill, severely psychotic patients
with globally disordered attention and cognition should
not be interviewed at such a stage. One has to await clini-
cal improvement before conducting the interview. Men-
tally retarded patients are probably unable to yield reli-
able information (the EASE has not been tested in sam-
ples of retarded patients).
Conduct of the Interview
The interview should ideally be performed in a semi-
structured way. It requires that the interviewer is inti-
mately familiar with the checklist and its distinctions.
The most frequent source of unreliability is the lack of fa-
miliarity with these distinctions. A totally unstructured
interview also tends to diminish reliability.
It is allowed to propose to the patient examples of path-
ological experiences, but it is always necessary to verify
the presence of the investigated item of experience by
asking the patient to describe in detail in his own words
at least one concrete example. Never score a simple ‘yes’
to a question as a confi rmatory answer.
In the ideal situation (which is only approximatively
possible), the interview consists of a patient-doctor mutu-
ally interactive refl ection: the interviewer poses a ques-
tion, the patient tries to respond, then the interviewer
perhaps reformulates the answer by proposing an exam-
ple, and becomes corrected by the patient who provides
another example of his own and in his own words.
The interviewer tries to capture essential features of
the experience in question through further probing and
with imaginative variation; this means that the interview-
er, in his inquiry and the attempts to represent the pa-
tient’s experience, may change some aspects of the expe-
rience and retain others in order to strip the experience
of its accidental and contingent features. The purpose is
to grasp the features that are essential for this type of ex-
perience (e.g. essential differences between thought pres-
sure and rumination). Yet, it is important to recognize
the limits to this objectivation process. If pressed exces-
sively by the interviewer, the patient may suddenly fi nd
that the conversation topic has somehow changed, drift-
ing into something quite different from the original inter-
rogation and exploration. Moreover, all pathological sub-
jective experiences are never purely deformed isolates,
but are always embedded in the patient’s self-understand-
ing, thus ultimately demanding from a psychiatrist to
explore their subjective meaning and existential enac-
tion – in other words to apply a hermeneutic approach.
Thus, if potential connections between different experi-
ences are being explored [e.g. ‘what motivated you to
study mathematics?’ (say , the interviewer is trying to es-
tablish whether ambiguity intolerance had played a role)],
then it is essential that the inquiry is open-ended and the
answers are tried to become validated through rich, de-
tailed, maximally spontaneous descriptions on the part
of the patient. It is advisable to tape or videotape the in-
terview for documentation purposes and possibility of
reexamination and reliability checks.
Examination of Anomalous
Self-Experience
Psychopathology 2005;38:236–258
239
Domain and Item Sequence
The EASE should never be performed as the fi rst com-
ponent of the interview, because intimate rapport with
the patient is crucially important. Begin with a detailed
social interview, which is easy, fi rst because it is factual
and second, because most people like to talk about
themselves and their lives. Allow the patient to speak
freely, but within limits; otherwise the interview becomes
interminable. A social interview provides a basic picture
of psychopathology: e.g. patterns of interpersonal func-
tioning (e.g. behavior patterns across different ages, isola-
tion, insecurity, suspiciousness, sexuality), educational
achievements, work stability, tenacity, fl exibility, ability
to make choices, professional inclinations, or spare time
interests. The question with which part of the EASE one
should start should be contextually determined. The cur-
rent item sequence of the EASE is motivated by inter-
view-technical concerns rather than by theoretical con-
sideration.
As a rule, it is easiest to begin with the section on the
‘stream of consciousness’ and start to ask about ability to
concentrate, remember and think, make plans, then fol-
lowed by more specifi c questions on more abnormal phe-
nomena (e.g. thought block, thought pressure). These in-
troductory questions have a quite neutral medical or ‘neu-
rological’ aura, permitting gradual and progressive probes
and extensions into domains that are more emotionally
provocative. It is important to collect the maximum of
relevant information, if possible, when exploring the item
in question rather than returning to it at separate occa-
sions (which prolongs the session and may make an un-
favorable impression on the patient). If the interviewer
senses a good cooperation, the EASE questions may al-
ready be introduced at appropriate junctures during the
social interview (e.g. if the patients talks about his school
problems, it might be natural then to explore possible
cognitive dysfunctions). Yet, the interviewer should al-
ways keep track of an adequate covering of all sections of
the EASE schema (always have Appendix B in front of
you).
If the EASE is part of a more comprehensive interview
schedule, it is advisable to perform two sessions separat-
ed by a break or at two different days. The duration of an
average EASE interview is approximately 90 min.
Time Period Covered. This varies with the study pur-
pose, and may span from the antecedent 2 weeks to a
lifetime exploration. The latter is important for an overall
assessment of self-disorders, which tend to decrease in
frequency in the advanced illness stages.
Scoring. Items that were not asked about or not an-
swered should be left blank (no information). Otherwise
the scoring of frequency/severity follows the rules pro-
vided below in Appendix A. For practical reasons, we
have simplifi ed the ratings of frequency and severity to a
combined one-dimensional score. EASE-targeted kinds
of experiences that only occur in association with psy-
chotic experiences should be registered separately on the
scoring sheet (Appendix B).
Training
The interviewer must possess good prior interviewing
skills, detailed knowledge of psychopathology in general
and of the schizophrenia spectrum conditions in particu-
lar, and he should pass an EASE 3-day training course,
comprising (1) a 1-day theoretical seminar, (2) a number
of supervised interviews and (3) provisional assessment
of reliability. The background of the EASE is phenomeno-
logical – especially for grasping the nature of the self and
the subject-world relation – and a familiarity with phe-
nomenological description of the structures of human
consciousness is indispensable in using the EASE for
pragmatic, psychometric purposes. For information con-
cerning EASE seminars contact the project secretary Lou-
ise Dahl, Hvidovre Hospital (E-Mail Louise.Dahl@hh.
hosp.dk).
The Psychometric Properties
The items of the EASE overlapping with the BSABS
have been used in Copenhagen from the end of the 1980s
in the Copenhagen High Risk Study [Parnas et al., 1993]
and the Copenhagen Linkage Study [Matthysse et al.,
2004], with interrater reliabilities for single symptoms
between 0.6 and 0.9.
At the end of the construction process of the EASE, we
calculated Cohen’s kappa reliability coeffi cients on the
basis of videotaped semi-structured interviews with 14
inpatients below the age of 30. The single-item kappa val-
ues ranged from 0.6 to 1.0. Test-retest reliability within
a span of a 4-week period is currently being examined.
Reliability between the raters decreases from (1) live
semi-structured interviews performed by one rater, with
the possibility of supplementary questions from another
rater; (2) semi-structured interviews scored from a video-
tape, and (3) nonstructured videotaped interviews. We
do not have by now any information on the scorings of
hospital charts.
With respect to a possible factor structure, we exam-
ined 12–14 interview items, representative of the EASE
domains, in a sample of 155 fi rst-admitted patients [Han-
Parnas /Møller /Kircher /Thalbitzer/
Jansson/Handest/Zahavi
Psychopathology 2005;38:236–258
240
dest and Parnas, in press]. No factorial structure could be
detected. We repeated these analyses on our genetic/fa-
milial sample [Matthysse et al., 2004], likewise without
detecting a clear factorial structure.
Domains and Item Descriptions
1 Cognition and Stream of Consciousness
General description of the domain: A normal sense of
consciousness as continuous over time, fl owing, inhabit-
ed by one subject and introspectively transparent (imme-
diately or directly given) in a nonspatial way.
1.1 Thought Interference (C.1.1)
Contents of consciousness (thoughts, imaginations,
or impulses), semantically disconnected from the main
line of thinking, appear automatically (not necessarily
quickly or many), break into the main line of thinking
and interfere with it. Such thoughts are often (but not
always) emotionally neutral and they do not need to have
a special or extraordinary meaning. The patient may use
private designations to describe such thoughts (‘thought
tics’, ‘acute thoughts’, and ‘surrealistic thoughts’).
Thought interference often becomes intensifi ed in fre-
quency ending up as thought pressure
(1.3) (in this case,
both items are scored). Interfering thoughts may also feel
anonymous, impersonal [see diminished mineness in
distorted fi rst-person perspective (2.2.1) and loss of
thought ipseity below (1.2)].
1.2 Loss of Thought Ipseity [‘Gedankenenteignung’;
Including Distorted First-Person Perspective (2.2)]
A feeling that certain thoughts (usually interfering
thoughts: 1.1) may appear as deprived of the tag of mine-
ness [score here distorted fi rst-person perspective as well
(2.2.1)]. Thoughts feel anonymous, or otherwise indescrib-
ably strange (but not primarily in the sense of content ),
perhaps without a connection to the patient’s self, perhaps
as if they were not generated by the patient (‘autochtho-
nous thoughts’), yet the patient has no doubts that these
thoughts are generated in him, that he is their origin.
Another situation occurs in reading: the patient may
feel as if the text is simultaneously being read by someone
else (as if another subjectivity somehow participates in
the reading process).
The patient does have the rational conviction that he
is the origin of these thoughts.
Note: It is important to realize that the basic phenom-
enon in question which is disturbed is ipseity, i.e. auto-
matic mineness or fi rst-person perspective. Note, more-
over, that it is quite normal to experience thoughts or
ideas suddenly popping up in the mind (‘Einfall’), ideas
that cannot be said to be generated willfully (‘unbidden
thoughts’). Yet, in these cases, the sense of immediate or
prerefl ective ipseity never questions itself .
In the case of thought interference (1.1), the inter-
fering thoughts may have an anonymous quality, as
described here. Also, certain ruminative experiences
(1.6) may have this feature. In these cases, score all the
relevant items.
1.3 Thought Pressure (C.1.3)
A sense of many thoughts (or images) with different,
unrelated or remotely related meaning/content that pop
up and disappear in quick sequences without the patient
being able to suppress or guide this appearance/disap-
pearance of (ever new) contents of consciousness. Alter-
natively, all these thoughts seem to the patient to occur
at the same time (simultaneously). This symptom in-
volves
a lack of control, many changing thoughts, but
also a lack of a common theme and hence a loss of coher-
ence or meaning for the patient. The semantic content
of the thoughts may be distressing but also neutral or
even trivial, without any special personal signifi cance.
Often, this phenomenon is associated with spatializa-
tion of experience (1.8) where thoughts are experienced
in a spatialized way, and sometimes even with a subtle
acoustic quality (1.7).
Examples
‘My thoughts are pressing on the skull from the inside.’
‘It feels as if a swarm of bees was in my head.’
‘My thinking is like an intersection of freeways, with a constant
zoom! zoom! noise from the racing cars.’
1.4 Thought Block (C.1.4)
A subjective blocking of thoughts that can also be ex-
perienced as a sudden emptiness of thoughts, interrup-
tion of thoughts, fading (slipping away) of thoughts or loss
of the thread of thoughts. It can be purely subjective but
also observable as a gap in the patient’s speech.
Subtype 1
Blocking: without a new thought intruding after the
sudden disappearance of the old one. The old thought is
suddenly and completely lost without a new one replacing
it. After a while, the thinking resumes.
Examination of Anomalous
Self-Experience
Psychopathology 2005;38:236–258
241
Subtype 2
Fading: without a new thought intruding after the slow
and gradual disappearance of the old one. A fading of
thought does not have to happen continuously, but can
have a paroxysmal, phasic quality, i.e. a thought becomes
weaker, dimmed and then becomes clearer and distinct
again to fi nally ‘slip’ away.
Subtype 3
Fading combined with simultaneous or successive
thought interference (score 1.1 as well): old and new
thoughts exist side by side, while the new one becomes
more prominent (more centered), the old one slowly re-
cedes into oblivion. The old thought gradually and some-
times irregularly dies away (loss of its position in the focus
of consciousness = fading) and, simultaneously, there is
an intrusion and persistence of the new thought, increas-
ingly coming into the focus. Due to the interference of new
thoughts, there is no feeling of emptiness of thoughts.
1.5 Silent Thought Echo
A feeling that one’s thoughts become automatically
(involuntarily) repeated or somehow doubled.
There is no perceptualization like in ‘Gedankenlaut-
werden’ (1.7).
1.6 Ruminations – Obsessions (C.1.2)
(Usually) disturbing persistence or recurring of certain
contents of consciousness (e.g. thoughts, imaginations,
images): these contents may be associated with any past
event. It may have the form of meticulous recapitulation
of remembered events, or conversations of the day.
There are four subtypes, which may coexist.
Subtype 1
Primary ruminations: here, the patient is unable to
nd any reason for his tendency to obsessive-like mental
states; he simply e.g. rethinks and relives what happened
during the day – apparently not motivated by perplexity,
paranoid attitude, or sense of vulnerability or inferiority
(as in subtype 2).
Subtype 2
Secondary ruminations
(perplexity-related or self-re-
ferring): the obsessive-like states appear as a consequence
of a loss of natural evidence, disturbed basic sense of the
self or hyperrefl ectivity or they appear to be caused by
more primary paranoid phenomena (e.g. suspiciousness,
self-reference) or a depressive state.
Subtype 3
True obsessions: ego-dystonic (as in obsessive-com-
pulsive disorder, the patient considers them as silly,
strange, both because of their content and their involun-
tary intrusion) with ongoing internal resistance, and a
content that is not horrid or macabre.
Subtype 4
Pseudo-obsessions: obsession-like phenomena, which
appear more as ego-syntonic (hence there is none or only
occasional resistance), frequently with pictorial imagina-
tive character and with a content that is directly aggres-
sive, sexually perverse, or otherwise bizarre. May be anx-
iety provoking.
Subtype 5
Ruminations/obsessions with rituals/compulsions:
any of the four phenomena described above plus rituals
or compulsive behaviors. Rate all relevant items.
1.7 Perceptualization of Inner Speech or Thought
(‘Gedankenlautwerden’)
Thoughts or inner speech acquire acoustic and in more
severe states auditory qualities. The patient does not feel
that others can hear or have access to his thoughts or he
feels it only transiently, and is able to suppress this feel-
ing immediately (e.g. he does not leave the room because
of his fear that others may somehow hear his thoughts; if
that is the case, then it counts as a psychotic fi rst-rank
symptom of schizophrenia). In some patients, the symp-
tom occurs only during reading. ‘Gedankenlautwerden’
is initially restricted to the subjective lived space, and its
rst stages may be described as increasing experiential
distance between the sense of self and the inner speech:
the latter becomes gradually spatialized to a quasi-percep-
tual level. The patient does not hear his thoughts through
the ears (from the outside), but only internally. Eventu-
ally, in a severe psychosis, the patient may hear his
thoughts being spoken by other people or transmitted to
him through the media. Some patients think both in the
mode of ‘Gedankenlautwerden’ and in a ‘normal’, ‘silent’
way, whereas other patients have exclusively ‘Gedanken-
lautwerden’. It is often impossible to date the onset of
‘Gedankenlautwerden’; in other words, the symptom has
apparently always been present and is therefore experi-
enced as being entirely ego-syntonic.
There are certain other phenomena that are similar to
‘Gedankenlautwerden’, e.g. a patient somehow internally
sees his thoughts as being written down, sometimes like
on a fi lmstrip (subtype 2), which may also include a strong
Parnas /Møller /Kircher /Thalbitzer/
Jansson/Handest/Zahavi
Psychopathology 2005;38:236–258
242
feeling of experiential distance to one’s inner speech or a
kind of ongoing constant dialogue with oneself, which has
an explicit lexical character.
Subtype 1
‘Gedankenlautwerden’, internal (internally confi ned).
Subtype 2
‘Gedankenlautwerden’, equivalents (thoughts as a
written text).
Subtype 3
‘Gedankenlautwerden’, internal as a psychotic fi rst-
rank symptom (afraid that others can hear his thoughts,
because they are so loud).
Subtype 4
‘Gedankenlautwerden’, external (or external thought
echo, where the patient has a feeling that his thoughts are
repeated or somehow resonate) as external auditory hal-
lucinations.
1.8 Spatialization of Experience
Thoughts, feelings, or other experiences or mental pro-
cesses are spatially experienced, i.e. as being localized to
a particular part of the head or brain or are being de-
scribed in spatialized terms (e.g. location, spatial relation
or movement).
Examples
‘One thought in front of the other.’
‘Thoughts are encapsulated.’
Thoughts ‘spiral around’ inside his head.
She experienced that her thoughts were in the right side of her
head and felt a pressing sensation from the inside of her skull
as if there was no more room for her thoughts.
‘Thoughts always pass down obliquely into the very same
spot.’
1.9 Ambivalence (A.5)
Inability to decide between two or more options. Per-
sistent and painful conscious coexistence of contradic-
tory inclinations or feelings. Ambivalence occurs even for
very simple or trivial everyday decisions. The patient
cannot decide at all, needs more time for his decision, or
becomes immediately uncertain about a fi nally made de-
cision and changes it again. A related phenomenon that
is scored here is when the patient complains of having
contradictory thoughts or feelings at exactly the same
time. This phenomenon may be associated with perplex-
ity and paralysis of action. The indecisiveness occurs in
everyday situations such as: what dish to cook, or what
to buy, which brand of a product to choose; e.g. the pa-
tient may prefer shopping at a gas station due to fewer
products to choose from (and fewer other customers).
Not rated here: Diffi culties in deciding between differ-
ent options that have a great impact on the patient’s fu-
ture – e.g. what job to take, whether to buy something
really expensive for which a loan has to be raised.
Examples
She has diffi culty in making decisions because she ‘considers
things in many ways’. Yesterday, it took her 3 h to decide on
which gift to buy for her boyfriend.
At the teachers’ college, she reversed her choice of subjects three
times but still couldn’t make out whether she had made the right
choice.
He is ‘snowed under with options’; e.g. he thinks that he prob-
ably ought to become a vegetarian even though he loves meat.
Such considerations lead him into ‘doubleness’ and ‘silly, blind
alleys’.
Each time I think of something, I get a counterthought on the
other side of the brain [score here also spatialization of experi-
ence (1.8)].
1.10 Inability to Discriminate Modalities of
Intentionality
Brief occasions or longer periods with diffi culties in the
immediate awareness of the experiential modality one is
currently living or experiencing. The patient may be uncer-
tain whether his experience is a perception or a fantasy, a
memory of an event or a memory of a fantasy. This phe-
nomenon applies to affectivity as well: the patient may be
unable to discriminate between different affects, feelings or
moods. He may experience (usually negative) mental states
that he is unable to designate or describe (has an experience
that he does not know – has no words for it). He may be
unsure whether he had spoken loudly or had just thought.
Comment: These phenomena are probably very fre-
quent in the schizophrenia spectrum conditions. Note
that in a normal experience, e.g. in a perceptual act, the
perceptual act is immediately and prerefl ectively aware
of itself; it is an instance of ipseity. In other words, when
I perceive or I think something, I do not become aware
of the fact of my perceiving or thinking by some refl ec-
tive/introspective examination of my current mental
activity and comparing it with other possible modalities
of intentionality (e.g. fantasizing). Any experience, any
intentional act, is normally articulated as ipseity, i.e. it
is automatically prerefl ectively aware of itself. The dif-
culties in this domain point to a profound disorder of
ipseity.
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1.11 Disturbance of Thought Initiative or Thought
Intentionality (C.1.13)
A subjective disturbance of thought initiative,
‘thought energy’ and intellectual purpose. This symptom
may be a subjectively experienced counterpart of the ob-
servable lack of goal orientation, in the sense of mental
planning and structuring of a task. Disturbances of
thought initiative and ‘energy’ also show themselves in
an impaired ability to self-initiate and structure certain
actions such as cooking, or writing an essay.
1.12 Attentional Disturbances
Subtype 1
Captivation of attention by a detail in the perceptual
eld (C.2.9). A particular visual feature or a part of the vi-
sual fi eld stands out from the background, almost isolated
and somehow pregnant, so that this single aspect of the fi eld
captures one’s entire attention. The patient has to stare at
this detail, although he does not want to do so (fi xation of
perception, spellbound) and he has diffi culty in moving at-
tention away from it. The perceptual detail usually does
not possess any particular symbolic or psychological sig-
nifi cance [in contrast to intrusive derealization (2.5.2)].
Subtype 2
Inability to split attention (A.8.4). Diffi culty in dealing
with demands involving more than one perceptual mo-
dality, such as simultaneous processing of visual and au-
ditory stimuli.
1.13 Disorder of Short-Term Memory
Diminished capacity to keep certain things in mind
for more than a few minutes. Although the subjects un-
derstand the content of a story or a conversation, they are
unable to remember and recall it. They report that they
are unable to read a book or see a movie, because they
forget the beginning as they proceed.
1.14 Disturbance in Experience of Time
A fundamental change in the experience of time, either
as a change in the subjective time fl ow, or with respect to
existential historical time, like past versus future (changes
in fl ow speed elicited by feelings of pleasure or by being
bored shall not be included here).
Subtype 1
Disturbance in the subjective experience of time fl ow:
e.g. a sense of time rushing ahead, time slowing down,
standing still, or time losing its continuity and becoming
fragmented.
Subtype 2
Disturbance in the existential time: e.g. life appears to
be restricted to the present, without guiding future pro-
jects, or the present is overwhelmed by stereotyped/re-
petitive reliving of a congealed past, or the experience
towards the future is felt as blocked or not available at all
(specify the exact nature of the phenomenon).
Example
The patient may feel discordance between a sense of ‘inner stag-
nation’ of his subjective life and the forward movement of the
surrounding world (subtype 2).
1.15 Discontinuous Awareness of Own Action (C.2.10)
This symptom consists of a break in the awareness of
one’s own actions. The patient reports that he cannot re-
member a certain short period of time, during which he
was carrying out an action, e.g. he cannot remember how
he found himself in the kitchen, or in a certain part of
town. The symptom overlaps dissociative fugue.
1.16 Discordance between Intended Expression and
the Expressed (A.7.2)
Subjective experience of not being able to express one-
self according to one’s actual feelings and emotions. The
patient experiences that his speech, behavior, gestures
and facial expressions are not in line, or congruent, with
what he feels; his expressivity is felt to be disfi gured and
distorted and somehow beyond self-control.
1.17 Disturbance of Expressive Language Function
(C.1.7)
Self-experienced impediment of speech, with a defi -
cient actualization or mobilization of adequate words.
The patient recognizes an impairment and retardation of
his word fl uency, precision, or availability. He cannot re-
call the precise words, or it takes him much longer to mo-
bilize them. Sometimes he recalls words that are only
peripherally and imprecisely associated with the context.
The patient may cope with this disturbance by using
common, customary and well-known expressions, say-
ings (cliché language), or by keeping silent and avoiding
conversation (secondary autism).
2 Self-Awareness and Presence
General description of the domain: A normal sense of
being (existence) involves automatic unrefl ected self-
presence and immersion in the world (natural, automatic,
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Psychopathology 2005;38:236–258
244
self-evident). This phenomenological concept of presence
implies that in our everyday transactions with the world,
the sense of self and sense of immersion in the world are
inseparable: ‘Subject and object are two abstract mo-
ments of a unique structure which is presence [Merleau-
Ponty, 1962, p. 430].
This unrefl ected immersion consists of two interde-
pendent components (moments):
(1) Unrefl ected self-presence; self-awareness; intact
rst-person perspective; ‘transparency’ or ‘clarity’ of con-
sciousness, intact ‘mineness’ of experience.
(2) Unrefl ected presence/immersion/embeddedness in
the world.
There is a general agreement in phenomenology that
these two aspects are mutually intertwined at a phenom-
enological level. In other words, a disorder affecting one
of the components will leave its imprint on the other com-
ponents as well. We may speak of a (normal) self-presence
whenever we are directly (noninferentially) conscious of
our own thoughts, perceptions, feelings or pains; these ap-
pear in a fi rst-person mode of givenness that immediately
reveals them as our own. If the experience is given in a
rst-person mode of presentation to me, it is given as my
experience and counts as a case of basic self-consciousness.
To be aware of oneself is therefore not to apprehend a self
apart from experience, but to be acquainted with an ex-
perience in its fi rst-person mode of presentation, that is,
from ‘within’. The subject or self of the experience is a
feature or function of its givenness. This basic self-aware-
ness (ipseity) is a medium or a mode in which specifi c in-
tentional experiences, such as perception, thinking, or
imagination, articulate themselves. In other words, in a
normal experience, there is no experiential distance be-
tween the sense of self and the experiencing.
This basic self-presence is normally presupposed in
experience; in itself, it does not possess specifi c experien-
tial qualities. However, the disturbed self-presence is of-
ten associated with the following clinical features: dimin-
ished clarity or transparency of consciousness, dimin-
ished sense of vitality or basic aliveness, diminished
activity potential or pleasure capacity, diminished sense
of attraction by the world, diminished sense of fi rst-per-
son perspective (mineness or ‘zero point of orientation’),
disorder of identity, and varying degrees of alienation.
In incipient schizophrenia, the prerefl ective self-aware-
ness is distorted; this distortion comprises a variety of
qualitative changes in experience that are different from
sopor and from other phenomena that occur in organic
conditions.
Anxiety is also explored in this section, although it
does not per se refl ect self-disorders. There are important
practical reasons for this addition: it permits exploration
of suffering, often involved in the morbid self-transfor-
mation and designated as anxiety by the patient, and sec-
ond, the item ‘ontological anxiety’, which is closely linked
to self-disorders, cannot be scored unless one has suffi -
cient information concerning anxiety.
2.1 Diminished Sense of Basic Self
A pervasive sense of inner void, lack of inner nucleus,
a pervasive lack of identity, feelings of being anonymous,
as if non-existent or profoundly different from other peo-
ple (this difference may sometimes be specifi ed as differ-
ence in the worldview, being linked to an existential ori-
entation that is fundamentally different than that of fellow
humans). This item also includes a subjective feeling of
‘overadaptation’, i.e., always, in a given moment, a neces-
sity to accommodate to the others’ opinion or their point
of view, linked to a dominating feeling of not having one’s
own inner standpoint (‘innere Haltung’; ‘Haltlosigkeit’).
Lack of basic self may be associated with a pervasively
negative self-image, which the subject describes monoto-
nously as a sort of eternal ‘shame’ or ‘sense of inferiority’
(i.e. devoid of a comprehensible relation to concrete con-
texts), ‘anxiety’, or ‘depression’; see Min kowski’s ‘regret
morbide’ as being indicative of autism. (See comment on
the overlap between 2.1 and 2.2, p. 245)
Subtype 1
Childhood onset: rate here such experiences that have
occurred early in life, i.e. already in early childhood or
during school age (primary school): the patient has always
felt to be profoundly different from his peers.
Subtype 2
Adolescence onset: rate here if the experiences have
occurred from adolescence until now.
NB: Subtypes 1 and 2 are not mutually exclusive. Often
the feeling of being different is primarily presented as iso-
lation/inferiority feelings/social anxiety/feeling more stu-
pid than others or it is ascribed to familial peculiarities (e.g.
father’s strange occupation). Only after a certain penetra-
tion, one may succeed in bringing forth these feelings of
difference. These feelings may be associated with solipsistic
features described in section 5 (existential reorientation).
In case of doubt of whether the experience should be
scored here or, alternatively, under distorted fi rst-person
perspective (2.2), score it positively in both.
Examination of Anomalous
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Psychopathology 2005;38:236–258
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Examples
It is as if I am not a part of this world; I have a strange ghostly
feeling as if I was from another planet. I am almost nonexistent.
She feels that her inner nucleus, her innermost identity, has dis-
appeared.
A feeling of total emptiness frequently overwhelms me, as if I
ceased to exist.
A patient felt ‘as if not existing any longer’; ‘I have lost contact
to myself’.
A patient feels as if he is a vacuum, which is motionless, while
the surrounding world is in motion.
During his adolescence, he tried hard to ‘gain human dignity’.
He explained the sense of lacking dignity as a feeling that his
own existence was as of a dispensable object, as if he was a thing,
a refrigerator, and not a human subject.
NB: Here, a distorted fi rst-person perspective (2.2.1) should also
be scored on the basis of his lacking a sense of being the subject
at all.
He avoids gatherings and discussions, because it becomes pain-
fully apparent to him that he never has an opinion of his own.
He feels that he does not have a stable inner nucleus and no
xed point of view. He always agrees with all the arguing parties
and fi nally gets confused.
2.2 Distorted First-Person Perspective
This item comprises at least three subtypes of the phe-
nomenon:
(1) Decreased or temporally delayed sense of mineness
or decreased sense of subjecthood (of being a human sub-
ject).
(2) Pervasive phenomenological distance between the
self and experiencing (constant self-monitoring).
(3) Spatialization of the self.
(See comment after the examples on the overlap be-
tween 2.1 and 2.2, p. 244)
Subtype 1
Own thoughts, feelings and actions may appear some-
how as impersonal, anonymous, and mechanically per-
formed. The sense of immediate ‘mineness’
of thinking,
feeling, and action may be diminished in an even more
explicit manner (e.g. the patient says that his thoughts
appear as if they were not generated by him, as in certain
forms of thought interference) or the feeling of mineness
only appears temporally (‘split second’) delayed.
He may feel as if he is an object, a thing, without sub-
jectivity, is no longer ensouled.
Subtype 2
There may be a profound experiential distance (phe-
nomenological distance) between the (sense of) experi-
ence (thinking, action, perception, emotion) and the sense
of self. In a normal experience, the sense of self and ex-
perience is but one and the same thing; they are com-
pletely fused. Also, in a normal introspective experience,
the introspecting self and the self that is being introspect-
ed are felt as one and the same. In the case of phenomeno-
logical (experiential) distance, there is a constant self-
monitoring, in which the patient excessively takes himself
as an object of refl ection. It is associated with turning
away from the external world and may prevent the patient
from a natural, smooth engagement in the interactions
with the world (in other words, anomalous experiencing
has tangible consequences). In the phenomenological (ex-
periential) distance, the self is, so to speak, ‘observing’ its
own mental contents and activities and this state may
intensify into a sense of having a double or a split self (see
hyperrefl ectivity and I-split). This state must be perva-
sive
2
, and not just occasionally appearing or voluntarily
provoked by the patient; the patient must experience the
phenomenological distance either as a constant or quite
frequent condition or as a problem or affl iction.
NB: See the items on hyperrefl ectivity (2.6) and I-split
(2.7). The states of hyperrefl ectivity, rated later, are less
pervasive, less intense or distressing and may be partly
subjected to a voluntary control.
Subtype 3
The sense of self as the absolute experiential point of
orientation [i.e. as something which does not itself have
a precise location (me who is here; the self identical with
all experiencing) but to which everything else is spatially
related (ego- centric space)] or as a pole/source/focus of
experience or action (I-consciousness) may be felt to be
at a specifi c spatial location or to have characteristics of
extension, or sometimes being spatially dislocated [in
both cases, always rate also spatialization of experience
(1.8)].
Examples
To subtype 1
I have a feeling as if it is not me who is experiencing the world;
it feels as if another person was here instead of me.
My feeling of experience as my own experience only appears a
split second delayed.
I have had ‘slightly strange experiences of a lacking relation be-
tween myself and what I am thinking’.
2
The introspective tendency is frequent in some schizophrenic patients. The
requirements of pervasiveness and/or affl iction are introduced here to demar-
cate the cases where the normal fi rst-person perspective must be considered to
be severely disturbed.
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Psychopathology 2005;38:236–258
246
She often has a feeling that it is not herself who performs her
own actions (e.g. writing) but she knows that it is not the case.
A patient feels that she ‘disappears’, ‘fades away’, her voice ap-
pears alien, ‘as if it came from a vacuum’. [This particular ex-
perience may also be scored as diminished sense of basic self
(2.1), yet here, the feeling of mineness appears as being clearly
affected as well].
I do not really feel as a human subject, as a person with a soul;
I feel like a dispensable thing, like e.g. a refrigerator.
To subtype 2
• My rst-person perspective is replaced by a third-person per-
spective (further explained by the patient that he constantly
witnesses his own experiencing).
I constantly regard myself. Sometimes it is so pronounced that
I can hardly follow what’s going on on TV. Even during a con-
versation with others, I observe myself to the point of having
diffi culty in grasping what my interlocutors are saying.
To subtype 3
My own ‘I’, as a point of perspective, feels as if it had shifted a
few centimeters backwards.
Comment on overlap: The two preceding items ‘di-
minished sense of basic self ‘ (2.1) and ‘distorted fi rst-
person perspective’ (2.2) overlap clinically at a descrip-
tive level because they are conceptually and phenome-
nological related. The reasons behind the separation of
the two are the following: fi rst to enrich the descriptive
properties of the EASE, and second, to separate less
characteristic from more characteristic anomalies. A
positive rating of diminished sense of basic self may
happen on the inferential evaluation of vague com-
plaints about a weak sense of personal identity. There is
therefore always a risk that such complaints stem from
identity disorders that affect the narrative self (e.g. as in
non-spectrum personality disorders), rather than the
more fundamental and structural disorders of ipseity
and I-consciousness. Distorted fi rst-person perspective,
on the other hand, only contains items that specifi cally
refl ect an anomalous structure of experience (ipseity and
I-consciousness).
2.3 Other States of Depersonalizations
(Self-Alienation, B.3.4 Reduced
3
)
A pervasive and diffuse sense of being alienated from
oneself, one’s own mental operations, thoughts, emotions
and behaviors, in a way that has not been captured by
other items of this section.
Depersonalization described here belongs to the range
of phenomena of disturbed self-awareness described in
this entire section and with a particular affi nity with the
disorders of basic self and fi rst-person perspective.
There are two subtypes: melancholiform depersonal-
ization and unspecifi ed depersonalization.
Subtype 1
Melancholiform depersonalization: it is well estab-
lished that melancholic mood change and the concomi-
tant sense of the altered fl ow of time are, so to speak, not
felt by the ego, but rather happen separately, i.e. in a cer-
tain dissociated way. In nonmelancholic depression and
in mourning, the ego is depressed – there is no distance
between the subject and his tristesse. In melancholia, on
the other hand, the ego cannot identify with the simulta-
neous inner changes consisting of slowing/arrest of vital-
ity (inhibition), blocked orientation towards the future,
and immobile mood change. It may be said that the ego
witnesses his own feeling disturbance; the melancholic
suffering is to no small degree caused by the inability to
enter into a relation with these disturbances. The patient
has a feeling that he is somehow changing, that something
wrong and burdensome is complicating his interior life;
he may appear suffering and confused/perplexed. Usu-
ally, it requires additional interviewing effort to disclose
typical melancholic elements. Note that the symptom
must present itself as a state phenomenon. There is no
disorder of the basic self (as a trait phenomenon) and
there is no disturbance in the fi rst-person perspective or
mineness.
Example
I do not feel myself, there is something in me which bothers me;
I don’t know what it is, but I cannot live like that (the appear-
ance of the patient was of a typically depressed person with
troubled, suffering expression. His state was preceded by a hy-
pomanic period of 4 months’ duration).
NB: Differential diagnosis between schizophrenia
spec trum and affective illness should never be based sole-
ly on the qualities of depersonalization.
Subtype 2
Unspecifi ed depersonalization: a feeling of alienation
that cannot be specifi ed more concretely in terms of qual-
itative experiential anomalies.
Example
I do not feel myself, I feel somehow changed.
3
The original BSABS item B.3.4 is a composite phenomenon. Certain di-
mensions have therefore been moved from it into other items. Consequently,
the present EASE item 2.3 is a sort of residuum.
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2.4 Diminished Presence
A decreased ability to become affected, incited, moved,
motivated, drawn, infl uenced, touched, attracted or stim-
ulated by objects, people, events and states of affairs. This
decrease should not be understood as active and deliber-
ate withdrawal, but more as something that affl icts the
patient and hinders his life. The patient does not feel
fully participating or entirely present in the world; he may
feel a distance to the world, which may be accompanied
by changes of world perception. This item includes both
physical and social hypohedonic states as well as apathy
(lack of feelings).
Subtype 1
Specifi ed: a pervasive sense of not being affected by
the external world, a lack of resonance, lack of natural
and spon taneous engagement, impossibility of immer-
sion, complaints of not being properly present
in the
world. This item includes social hypohedonia, a dimin-
ished emotional and cognitive reactivity, apathy (i.e. feel-
ing of not having feelings) or a pervasive sense that ev-
erything is or seems meaningless [in this latter case, there
is a possibility of overlap with lack of natural evidence
(2.12) and derealization (2.5)].
NB: Social hypohedonia should never be rated as pres-
ent in the case of concomitant social anxiety
(2.13.4) un-
less these two appear to occur independently of each oth-
er. It is important to assess potential trait-state status of
these experiences (the latter are strongly suggestive of
schizophrenia spectrum). It is also important to check for
clinical depression, especially in subtype 1.
Example
Everything appears utterly indifferent to me.
Subtype 2
Nonspecifi ed: a pervasive nonspecifi ed (quasi-per-
ceptual) feeling of distance to the world, or a sense of a
barrier between one-self and the world (a feeling of being
enclosed in a ‘glass case’ or being behind a glass). Yet this
sense of distance cannot be specifi ed by the patient in
further details, e.g. in terms of specifi c perceptual/ex-
periential changes (e.g. if the ‘glass case’ patient seems to
experience looking through a glass, then it is subtype 3)
.
Subtype 3
Including derealization or perceptual change (section C
in the BSABS): as subtypes 1 and 2 but accompanied by an
explicit change in the perceptual feeling tone (in other words,
the sense of barrier can be described by certain explicit prop-
erties: e.g. colors are faded; objects are remote) or marked
by more specifi c perceptual disturbances, or dereal
ization
(i.e. everything seems to be unreal, lifeless, mechanic).
Comment: All three subtypes are not mutually exclu-
sive and may overlap with derealization and other self-
disorders. The main difference between diminished pres-
ence (2.4) (especially its subtypes 2 and 3) and derealiza-
tion (2.5) is that in diminished presence, the patient
locates the sense or the source of change primarily in him-
self, whereas in derealization it is predominantly the en-
vironment that appears changed for the subject.
2.5 Derealization (C.2.11)
A change in the experience of the environment: the
surrounding world appears somehow transformed, un-
real, and strange, may be compared to an ongoing movie.
There is a decrease in the very primary sense of lived real-
ity, but no decrease of conceptually based reality aware-
ness or of reality testing.
The source of change is not felt as primarily located in
the patient.
Subtype 1
Fluid (global) derealization: this is by far the most
common subtype of derealization. The change is hard to
describe and specify explicitly. There is a dilution or fad-
ing out (or even a loss) of the physiognomy (Gestalt mean-
ing) of the surrounding world: the meaning and the sig-
nifi cance of the world appear changed, unclear, or am-
biguous. The world appears as strange and alien,
mechanic, lifeless, or meaningless.
Subtype 2
Intrusive derealization: here, there is an increase or
accentuation of the physiognomy of the world or of its
isolated aspects or components, thus often occurring to-
gether with a captivation by details of perception (1.12.1).
Single, isolated aspects of the environment (objects, situ-
ations) acquire intrusive or obtrusive experiential quali-
ty, with indeterminately increased signifi cance and may
be experienced with increased emotional tag.
The phenomenon must not be voluntarily induced
through sustained attention (constant staring), although
staring may amplify preexisting derealization.
Examples
To subtype 1
The surroundings appear to me as unreal, changed.
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Psychopathology 2005;38:236–258
248
Things are no longer the way they used to be. They are strange,
as if they only were silhouettes.
To subtype 2
The behavior of the dog made a strong impression on me; it was
so wild, uncontrolled, so full of pure nature, savage and instinct-
driven that I felt warmth in my heart. Also that wild horse, and
that old woman, with her face marked by the age; the whole
landscape was so authentic, so primordially natural; it was all so
moving that I felt an immense happiness’ [Matussek, 1952].
NB: Derealization may be accompanied by other and
more specifi c changes of perception (e.g. a change in the
quality/intensity of sounds). In the case of a clear percep-
tual change, score diminished presence as well (2.4.3).
Derealization felt just after a panic attack should not be
rated here.
2.6 Hyperrefl ectivity; Increased Refl ectivity (B.3)
Occasionally excessive or frequent, even chronic, ten-
dency to take oneself or parts of oneself or aspects of the
environment as objects of intense refl ection. The patient
typically suffers from a loss of naïveté, leniency, and ease.
There is an increase in the tendency to refl ect about one’s
own thinking, feelings and behavior, and inability to react
and behave spontaneously and carefree; a tendency to
excessively monitoring inner life, while at the same time
interacting in the world (‘simultaneous introspection’
4
).
In the case of loss of common sense (2.12) (rated sepa-
rately), there will be an automatically increased tendency
to refl ect about the world.
NB: The intensity of hyperrefl ectivity in this item is
less than what is the case in distorted fi rst-person perspec-
tive (2.2.2), where the condition is so pervasive and in-
tense that it leads to a constant feeling of phenomeno-
logical distance.
Examples
I had to think about what to think.
She has always been ‘self-refl ective’ and thought about herself
‘in an existential way’.
2.7 I-Split (‘Ich-Spaltung’)
The patient experiences his I, self, or person as being
divided or otherwise compartmentalized, disintegrated
into semi-independent parts, or not existing as one uni-
ed whole. The patient’s complaints must have an expe-
riential quality that may form a continuum from a vague
sense of split, ‘as if’ division, to a split that is elaborated
in a delusional way. It does not suffi ce to score this item
in cases where the patient is aware of having, e.g., a ‘mul-
tifaceted personality’.
Subtype 1
I-split suspected: rate here cases of I-split which the
interviewer suspects are present behind the patients’ com-
plaints, yet without being able to point out specifi c expe-
riential terms used by the patient; i.e. this rating is based
on statements suggesting a split, but which the patient is
not able to conceptualize in explicit terms and is therefore
vague and unclear.
Subtype 2
The rating of I-split is based on reports of ‘as if’ expe-
riences.
Subtype 3
The I-split involves a spatialized experience not in-
volving delusional quality.
Subtype 4
The I-split involves a delusional elaboration.
Examples
To subtype 1
After he was transferred to a single room and left alone, he got
a thought ‘now, we two old chaps are alone together’, and the
thought surprised him.
To subtype 2
Approximately, once a week, she had a feeling ‘as if she was two’,
‘as if she was able to see herself from the outside’. ‘She splits up
into two parts and fl ies away, composed of those two parts’.
NB: Score also dissociative depersonalization (2.8).
She says that her thoughts ‘divide themselves’, and she feels a
split in herself. It is a question of negative and positive thoughts.
She feels it as if there were two different parts of her which
‘carry out a war with each other’.
He describes that he often has no contact to his left side; it feels
as if he ‘was half’ only. This feeling can propagate itself into the
depth of his body.
NB: Here, score also somatic depersonalization (3.3).
To subtype 3
Her right part is much stronger, and able to put up a façade. She
feels ‘imbalance in the layers of the two sides’.
She feels herself as a cranium with something inside, ‘a little
man in a cockpit’, as if she had two brains. One part of herself
feels somehow dissociated from her normal self and therefore
strange. The thoughts belonging to her normal self are localized
to the anterior part of the brain, whereas the thoughts that are
strange are located in the more posterior part in the brain.
There are two sides in her: one destructive and one positive.
Once, when she was in bed, she got for some seconds a feeling
that she was transformed into two persons, who were both lying
in the bed.
4
This is a term borrowed from Japanese psychopathology (M. Nagai).
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To subtype 4
A young female patient (with prior anorectic episodes) ex-
plains that she has always ‘felt wrong’; from time to time she
stopped eating in order to starve the wrong part to death. (In
this particular case, the statement approaches a delusional
quality).
2.8 Dissociative Depersonalization (Out-of-the-Body
Experience)
The patient says that he sometimes feels as if he was
‘outside’ himself as a sort of a double, watching or observ-
ing him or others. The experience must have the ‘as if’
character (subtype 1), i.e. the patient does not actually per-
ceive himself from outside, but only imagines doing so for
his ‘inner eye’; a kind of ‘out-of-the-body’ experience.
If there is an instance of self-perception from without,
the experience should be considered as a dissociative vi-
sual hallucination (subtype 2) (e.g. the patient says that
he is literally seeing himself from the outside, or seeing
his double next to him).
However, in many cases of these ‘out-of-the-body’ ex-
periences, it may be impossible to grasp what the patient
actually means with the expression: ‘watching himself
from outside’ – perhaps it may even not be an imaginative
process but a description of experiental distance (2.2.2) or
a ‘simultaneous introspection’ in hyperrefl ectivity (2.6).
Subtype 1
‘As if’ imaginative phenomenon.
Subtype 2
Dissociative visual hallucination.
2.9 Identity Confusion
A feeling as if the patient is somebody else.
Examples
‘I feel as if I were my own mother.’
A patient was briefl y able to feel as if he was another person, of
whom he happened to be thinking. He does not know whether
it was a physical or mental experience.
A patient briefl y felt as if he was a dog.
NB: Identity confusion would frequently be associated
with a diminished sense of basic self (2.1), distorted fi rst-
person perspective (2.2) and transitivism (4.0).
2.10 Sense of Change in Relation to Chronological Age
A fundamental feeling as if being considerably older
or younger than the actual chronological age, not clearly
understandable because of social relations or interac-
tions.
Examples
He may feel younger and in fl ashes he may feel like another
person.
NB: Rate also identity confusion (2.9).
During a conversation, she says that she feels like a 5-year-old
girl. At the next appointment, she repeats that she felt like a
little girl.
2.11 Sense of Change in Relation to Gender
Subtype 1
Occasional fear of being homosexual or that others
consider one as such.
Subtype 2
A feeling as if being of the opposite sex or a confusion
of ones own sex.
2.12 Loss of Common Sense/Perplexity/Lack of
Natural Evidence
It is a loss or a lack of automatic, prerefl ective grasp of
the meaning of everyday events, situations, people and
objects.
There are different domains in which this feature
may manifest itself. The patient may be unable to grasp
signifi cation of everyday matters and situations (e.g. he
may wonder about colors of traffi c lights), may not un-
derstand the (tacit) rules of human conduct or interac-
tions, or may become excessively intrigued or preoccu-
pied by semantic issues . The naturalness of the world
and of other people is lacking, and that usually leads to
a certain hyperrefl ectivity. This symptom should not be
rated if the major change comprises a persecutory pa ra-
noid threatening coloring of the world (‘Wahnstim-
mung’). The reaction of the patient is of perplexity,
curiosity, amazement, and attempts to understand
(through refl ecting) or to cope. Morbid rationalism and
geometrism are suffi cient but not necessary to rate this
symptom.
Explanation of the Terms
Morbid Rationalism. Refers to a general attitude of the
patient, who considers human moves, affairs and actions
as being guided by specifi c rules, rigid principles and sche-
mas: ‘A father buys a coffi n to his dying daughter as a
birthday present, because the coffi n is something she is
going to need’ [Parnas and Bovet, 1991].
Geometrism. Preoccupation with spatial arrangements
in the world, symmetry, mathematical or numerical as-
pects of the world; corresponds to certain lifeless rigid
obsessionality.
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Morbid Rationalism and Geometrism Overlap. Both
represent artifi cial stiffness versus an adaptive automatic
dynamism of ‘life’ (see Minkowski).
Examples
All the existential thoughts have mixed up the pieces in my
mental system. I don’t understand life. The whole image of life
has changed. So many questions, so little explanation!! Why are
we living?
He states that ‘nothing is relative’ in the sense that he fi nds no
connection between things in the world.
Language represents for her a confusing and overwhelming sea
of almost infi nite variation of meaning.
A patient started to doubt the meaning of the most ordinary
words. He bought a dictionary to learn these meanings from the
very scratch.
A patient always refl ected on self-evident features of the world:
why the grass is green, why the traffi c lights are in three colors.
Why do we have two eyes?
2.13 Anxiety
Subtype 1
Panic attacks with autonomous symptoms: the patient
experiences attacks of severe anxiety, lasting minutes to
hours, accompanied by at least two of the following: trem-
bling, chocking, palpitations, dizziness, hyperventilation,
and fear of dying. It may also be accompanied by fear of
disintegration or losing one’s mind, followed by dereal-
ization, or feelings of self-reference. Such attacks may be
triggered in a nonspecifi c way by external stimuli (e.g. be-
ing alone).
Subtype 2
Psychic-mental anxiety: a strictly mental feeling of
anxiety and tension, perhaps accompanied by fear of dis-
integration, but without autonomous symptoms.
Subtype 3
Phobic anxiety: any anxiety that is provoked by spe-
cifi c stimuli such as open places, heights, small rooms, or
certain animals (excluding social stimuli).
Subtype 4
Social anxiety: insecurity provoked by social encoun-
ters, others’ gaze, close physical contact, parties, crowding
(may include self-reference).
Subtype 5
Diffuse, free-fl oating and pervasive anxiety: anxiety/
inner tension/indescribable unpleasant affect, which is
nearly constant, and may be provoked by a multitude of
stimuli or arise for no apparent reason, making life and
relations to others a nearly unbearable and a constantly
felt burden or a source of suffering (see also ontological
anxiety, 2.14).
Subtype 6
Paranoid anxiety: anxiety of any type linked to para-
noid ideation (being exploited, harassed, manipulated,
not respected).
NB: In case of overlap, rate all relevant subtypes.
2.14 Ontological Anxiety
A pervasive sense of insecurity, weakness, inferiority,
indecisiveness, low anxiety tolerance, persistent
low-
grade free-fl oating
(objectless) anxiety, or a subtle, perva-
sive sense of something ominous impending. The lifestyle
of a person with ontological insecurity is concerned with
self-preservation rather than with self-realization. The
world and the others are not experienced as invariant se-
cure existential foundations, but as enigmatic, unreliable,
or threatening. The patient has a pervasive sense of being
exposed, and a need to protect or hide himself. Such feel-
ings of ontological insecurity are nearly always associated
with a sense of profoundly disturbed identity, ambiva-
lence, loss of natural evidence, or hyperrefl ectivity.
NB: This feature should be rated very conservatively,
and can usually be detected only on the basis of an inter-
view, which includes information on social, interperson-
al, educational, professional functioning, interests, moti-
vations, and the exploration of subjective experience.
Therefore, the symptom should be scored as present only
in addition to anxiety (2.13.1; 2.13.2) or diffuse, free-
oating and pervasive anxiety (2.13.5) and there is simul-
taneous evidence of at least one of the following items:
ambivalence (1.9), diminished sense of basic self (2.1),
distorted fi rst-person perspective (2.2), depersonalization
(2.3), derealization (2.5), hyperrefl ectivity (2.6), or per-
plexity (2.12).
2.15 Diminished Transparency of Consciousness
A pervasive or recurrent sense of not being fully alert,
fully awake, fully conscious, as if there was some lack of
clarity, inner hindrance, or feelings of internal pressure,
blocking, opacity. The acts of consciousness or the very
way of being conscious appear as somehow peculiarly fad-
ed, diminished or ineffi cient.
If the patient complains about a sort of globally un-
pleasant, but not further describable pervasive mental
state, or a global feeling of pressure, oppression, blocking,
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and the like, locating these sensations to his head, mind
or brain, then diminished transparency should be rated
as present, that is if the complaints are not caused by a
concomitant thought pressure (1.3). Experiences of di-
minished transparency should not be rated if they appear
to be secondary, e.g. linked to thought pressure, halluci-
natory states, mental exhaustion, clinical depression, sea-
sonal affective disorder, and organic brain disorder (e.g.
epilepsy) or drug intake.
NB: Clarity is not used here as in the context of delir-
ium, where clarity is usually said to be lacking. Dimin-
ished transparency is very diffi cult to elicit during the
interview; it is frequently accompanied by other self-dis-
orders.
Examples
My feeling of consciousness is fragmented.
It is a continuous universal blocking, a strain.
I always feel ‘half awake’.
I always have a feeling of not having slept enough.
I have no self-consciousness.
Frequently, I have a strange foggy feeling in my head.
Typical vignette 1: ‘I have a feeling as if my brain is
shrinking.’ (Question: How? Please describe): ‘It’s like a
constant pressure inside my head, as if there was some-
thing wrong inside, and sometimes also like a ring or a
strap around my head. It hinders me in thinking and in
seeing properly’.
Typical vignette 2: A patient says that he is frequently
affected by ‘dizziness’, which means that he is ‘only in-
completely in contact with the world, only 60–70%. It is,
as if there was no hole (no opening) to the world. There
is a lack of transparency between me and the world’. He
emphasizes: ‘ It has nothing to do with perception, percep-
tual impressions or the senses.’
NB: In this case, there should be scored diminished
presence, subtype 2, ‘glass case’ (2.4.2), but also dimin-
ished transparency, because the patient’s experience ap-
pears to involve diminished transparence of conscious-
ness as a medium of experience (e.g. his insistence on the
fact that the problem is not located in the sensory pro-
cesses/perception).
2.16 Diminished Initiative (A.4)
A pervasive sense that all activity is requiring effort,
diffi culty in initiating action. In other words, it is not suf-
cient to score this item on the basis of inactivity, or
apathy. The patient must describe his inability to initiate
action (e.g. sits 3 h, preparing himself for going to the post
offi ce).
Exclusion criteria:
as in diminished vitality (2.18).
2.17 Hypohedonia
Hedonia refers to pleasure capacity. Pervasively or re-
currently occurring diminished ability to experience plea-
sure in relation to immediately surrounding ‘physical’
perceptual or intellectual stimulation [e.g. social anhedo-
nia is scored elsewhere (2.4)].
NB:
In contrast to diminished presence (2.4) described
above, we are dealing here with self-feelings associated
either with circumscribed bodily or mental states in rela-
tion to direct circumscribed environmental stimulation
(e.g. diminished pleasure in tasting food, taking a hot
bath, no pleasure from sex) or in relation to previously
pleasurable physical or intellectual activity (e.g. sport,
reading books). This defi nition follows the standard con-
temporary psychiatric defi nition. Yet, it is probably
doubtful that hypohedonia ever occurs singly, as a com-
pletely isolated phenomenon, e.g. unrelated to dimin-
ished vitality (2.18), diminished presence (2.4), or dis-
torted fi rst-person perspective (2.2). In the case of over-
lap, all relevant items should be rated as present.
Examples
I have lost all pleasure. Previously I loved to jog; now I’m not
interested in it.
I am unable to feel pleasure. Nothing gives me a kick.
2.18 Diminished Vitality (A.3.1)
A pervasive or frequently recurrent sense of inexpli-
cable mental or physical fatigue, dampening of immedi-
ate aliveness, diminished energy, spontaneity, ‘élan’.
Subtype 1
State-like diminished vitality occurs during exa cer-
bation(s) marked by other coexisting symptoms such as:
apathy, inactivity, staying in bed and other symptoms,
e.g. ruminations or feelings of bodily changes.
Subtype 2
Trait-like diminished vitality occurs more or less per-
vasively or as a frequently recurrent and relatively iso-
lated feature.
Exclusion Criteria
These phenomena should not be rated as present if
they are explicable by other, more primary or encompass-
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Psychopathology 2005;38:236–258
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ing disturbances such as thought pressure (1.3), hyperre-
ective ruminations (1.6), clinical depression (which in-
cludes melancholia and a major depression successfully
treated with antidepressants), organic brain disorder or
pharmacological side effects.
Faded or absent intentional feelings (apathy; i.e. feel-
ings specifi cally directed at someone, e.g. family, chil-
dren) are scored above as diminished presence (2.4).
Score both in case of doubt.
Examples
I have no energy, no inner spark.
I feel completely empty.
I always feel tired and exhausted; I saw a doctor but he could
not fi nd anything somatically wrong.
I have lost all form of desire. I have no contact to myself, I feel
like a zombie.
I lost my feelings, making me almost another person.
3 Bodily Experiences
General description of the domain: A normal sense of
psychophysical unity and coherence, a normal interplay
or oscillation of the body as ‘lived from within’ as a sub-
ject or soul (nonspatial, spiritual ‘Leib’) and of the body
as an object (spatial and physical ‘Körper’). In other
words, our bodily experience is neither of an object nor
of a pure subject. It is simultaneously both.
3.1 Morphological Change (D.9)
Usually paroxystic sensations (‘as if’) or perceptions of
diminishment or constriction of single body parts, or ex-
periences of body parts or the entire body becoming thin-
ner, shorter, contracting, enlarging, being pressed down
or diminished.
Subtype 1
Sensations
affecting the whole body or part of it and
generally paroxysmally.
Subtype 2
The patient perceives a morphological change in his
body: e.g. he sees his hands as enlarged (illusions of
change).
3.2 Mirror-Related Phenomena (C.2.3.6)
This is a group of phenomena, which have in common
an unusually frequent, and intense looking in the mirror
or avoiding one’s specular image or looking only occa-
sionally but perceiving a facial change.
The patients either perceive changes of their own face
or they look for such changes, and therefore examine
themselves in the mirror often and/or intensely. They
may become surprised or frightened by what they see, and
even tend to avoid mirrors because of what they see.
Sometimes they look in the mirror to assure themselves
of their very existence. They might also look at photos of
themselves to fi nd out about their own identity.
NB: In that case, score also diminished sense of basic
self (2.1).
Subtype 1
The patient only searches for change or frequently
looks in the mirror for a nonspecifi ed reason, but there is
no defi nite perception of change.
Subtype 2
The patient perceives his own face as somehow changed
or deformed.
Subtype 3
Other phenomena that may belong to this category
(e.g. to assure oneself of one’s existence).
Examples
To subtype 1
Lately, she has felt being somehow strange, not really herself,
perhaps absent-minded. Yesterday she had to look in the mirror
to check whether her face had changed.
NB: Here, psychic depersonalization (2.3) should also be rated.
To subtype 2
She had an experience that her face looked witch-like, and there-
fore she did not like to see herself in the mirror.
She saw that her neck muscles were strangely protruding.
When she looked at herself in the mirror, she focused on the eye,
which she suddenly saw as a ball in her head. It was ‘surrealis-
tic’, and she felt that her face was changed.
3.3 Somatic Depersonalization (Bodily Estrangement)
(D.1.1)
The body or some of its parts are perceived as strange,
alien, lifeless, isolated, separated from each other, dislo-
cated or not existing.
Examples
When I look down at the lower part of my body, it constantly
feels twisted and displaced to the left, compared to the rest of
the body.
I have a feeling that my left and right forearms have switched
places.
I have a strange feeling that it’s somebody else’s body.
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It is as if his body was alien. He knows that it is his body, but it
feels ‘as if it did not hang together’, it feels ‘as if his head was
just fi xed to the body’.
She always feels self-estranged, ‘as if there was a little man in
her head, steering this big robot’. Sometimes she looks at her
arms and hands, and has a feeling that they are not her own.
NB: In contrast to morphological change (3.4), where there is a
feeling or illusion of a specifi c morphological change, we are
dealing here with global, diffuse experiences.
There are cases where somatic depersonalization (3.3) and mor-
phological change (3.1) are not clearly distinguishable from each
other. If so, rate both positively.
3.4 Psychophysical Misfi t and Psychophysical Split
The body feels as if not really fi tting, as either too
small, too big, or otherwise uncomfortable or somehow
changed. This is usually, but not always, associated with
a feeling that mind and body do not fi t or belong together,
as if they were somehow disconnected, or independent
of each other.
NB: Do not score here a dislike of specifi cs or concrete
aspects of one’s appearance, e.g. weight, or height.
Examples
He lacks a ‘healthy self-acceptance’ of his body, it is diffi cult for
him to ‘possess, take care of it without feelings of inferiority and
shame’. It is diffi cult for him ‘just to be in his body’.
She has diffi culty in realizing that she is in her body, and she
may be thinking ‘it’s strange that I am here’.
He talks about ‘a lack of coherence’ or split between his physical
part, visible to others, and himself, i.e. all that happens in his
mind. He feels that his body is a shared property, something
anonymous, distanced from him.
3.5 Bodily Disintegration
Feeling of bodily disintegration or dissolution, as if
falling apart or going bodily into pieces or disappearing.
NB: This experience may be linked to disorders of de-
marcation but is placed here for the interview conve-
nience.
3.6 Spatialization of Bodily Experiences
Predominance of experiencing the body or its parts as
a physical object (physical/spatial), at the expense of the
spiritual-lived, nonspatial, lived bodily experiences
.
The patient may here experience a kind of unusual in-
trospective access to normally mute body parts or physi-
ological processes (e.g. the patient experiences his internal
organs or physiological processes).
Examples
Her uterus feels as if it was not her own, as if it was somehow
detached.
NB: Somatic depersonalization (2.8) is also rated here.
I can feel the blood rushing under my skin.
3.7 Cenesthetic Experiences (D.1; 3–9; 11–14)
Unusual bodily sensations of numbness and stiffness:
a furry or numb feeling (e.g. in the hands, feet or other
parts of the body).
Unusual bodily sensations of pain in a distinct area,
not comparable to, completely different from premorbid-
ly known pains.
Migrating bodily sensations wandering through the
body.
Electric bodily sensations, feelings of being electrifi ed.
Thermal sensations (feelings of heat and cold).
Bodily sensations of movement, pulling or pressure
inside
the body or on its surface.
Sensations of abnormal heaviness, lightness or empti-
ness, of falling or sinking, levitation or elevation affecting
the whole body or just parts of it.
Vestibular sensations.
Dysesthesias provoked by sensory or tactile stimula-
tions: inconveniences, i.e. pain that is provoked by an
acoustic stimulus. Touch, which feels unpleasant and
painful.
Dysesthetic crises: paroxysmal states, lasting seconds
or minutes, which involve impaired bodily sensations,
central-vegetative disturbances and fear of dying.
3.8 Motor Disturbances
Subtype 1
Pseudo-movements of the body (D.10): the patient ex-
periences pseudo-movements of the body or parts of it,
e.g. the limbs (not to confuse with motor interference,
where real movements occur).
Example
A feeling of the body rocking or the leg jerking.
Subtype 2
Motor interference (C.3.1): motor or verbal derail-
ments that occur without or against the patient’s inten-
tion and typically interfere with intended motor actions
or speech. Such derailments are part of usually intended
behavior (pseudo-spontaneous movements, e.g. gaze
spasm, movement stereotypes, automatosis syndrome)
and are not regarded by the patient as being made or in-
uenced by external forces.
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Subtype 3
Motor blocking (C.3.2): impediment or complete
blockage of intended motor actions. Occurs as a parox-
ysm. Complete blockages (‘Bannungszustände’) may ap-
pear suddenly, like an attack or paroxysm and disappear
quickly. The patient is fully conscious, but is unable to
move or speak. These blockages can be regarded as coun-
terpart of the automatosis syndrome (C.3.1).
Subtype 4
Sense of motor paresis (D.2.): a sudden feeling of weak-
ness or paresis of the arms or legs on one or both sides of
the body. These ‘sensations of paresis’ might lead to limp-
ing or to things slipping out of the hand, to not being able
to hold tools so that work has to be stopped.
Besides short-lasting variants, long-lasting sensations
of paresis occur as well (persisting for weeks).
Subtype 5
Desautomation of movement (C.3.3): common every-
day, habitual actions (such as getting dressed, washing,
shaving, brushing the hair) that have been performed
more or less automatically in the past cannot be per-
formed any more or only with great effort of will power.
They take more time and have to be performed with max-
imal and conscious attention.
Partially automated performances (e.g. riding a bicy-
cle, knitting or working in the kitchen) are also disturbed.
Action routines that had been effortlessly available are
more or less completely lost.
3.9 Mimetic Experience (Resonance between Own
Movement and Others’ Movements) (C.2.3.7)
Pseudo-movements of perceived objects and humans
are experienced, especially when the patient is in motion
himself. Therefore, he will often try to avoid moving. Ei-
ther the patient or the object/human moves fi rst, or both
simultaneously, and the patient feels as if there is a strange
link between the two.
NB: Mimetic experience has affi nities with solipsistic
experience (domain 5). It is placed here for the interview
convenience, now focused on body and movement.
4 Demarcation/Transitivism
General description of the domain: Loss or permeabil-
ity of self-world boundary. These disorders are closely
linked to disorders of self-awareness and presence, but
are listed separately here because of their more articu-
lated symptomatic nature.
4.1 Confusion with the Other
The patient experiences himself and his interlocutor
as if being mixed up or interpenetrated, in the sense that
he loses his sense of whose thoughts, feelings, or expres-
sions originate in whom. He may describe it as a feeling
of being invaded, intruded upon in a nonspecifi c but un-
pleasant or anxiety-provoking way. In the extreme degree
of the latter, score also 4.3, subtype 1.
4.2 Confusion with One’s Own Specular Image
A feeling of uncertainty about who is who or who is
where, when looking at his own mirror or another specu-
lar image (e.g. in the window panes of the shops), or por-
trait pictures, and paintings.
4.3 Threatening Bodily Contact
Subtype 1
A feeling of extreme anxiety or unease
when standing
close to or being touched by another (even by a close per-
son), or being hugged. Bodily contact feels threatening to
one’s autonomy and existence. Sexual intercourse may be
unbearable.
NB: Do not rate this symptom when it appears caused
by a paranoid, suspicious attitude.
Subtype 2
A feeling of personal disappearance, annihilation, or
ceasing to exist, when being exposed to a close contact
with another, e.g. during a sexual intercourse.
4.4 Passivity Mood (‘Beeinfl ussungsstimmung’)
A diffuse feeling or mood of being somehow in a passive,
dangerously exposed position, at the mercy of the world, in
an unspecifi ed and unconcretized manner. It is a sort of
being oppressed by something negative that may happen
imminently, without any thematic specifi cation (overlaps
delusional mood). One’s sense of being a volitional autono-
mous subject is diminished, which may sometimes
necessitate scoring of distorted fi rst-person perspective
(2.2) as well. The patient has no concrete experiences or
delusional ideas about external infl uences, yet he feels as if
he was somewhat constrained by the external world.
4.5 Other Transitivistic Phenomena
Other feelings of inadequate bodily demarcation (also
versus inanimate objects), a pervasive feeling of being
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somehow ‘too open or transparent’ or having extraordi-
narily ‘thin skin’, having no barriers, or a state in which
the patient is excessively preoccupied with the exact mech-
anisms of self-world and self-other relations/infl uences, or
has a special ‘extra layer’ covering his body surface.
Varieties of heightened perception, where the patient
complains of insuffi cient barrier against sensory stimuli
(mainly optical), should also be scored here.
5 Existential Reorientation
General description of the domain: The patient experi-
ences a fundamental reorientation with respect to his gen-
eral metaphysical worldview and/or hierarchy of values,
projects and interests. Basically, the experiences of anom-
alies in self-awareness are here enacted and so existen-
tially expressed.
Solipsistic-Like Experiences (Items 5.1–5.6)
The patient in some way feels as if being a unique
(literally or in the sense of centrality) subject in the
world, may have a fl eeting sense of extraordinary abili-
ties or powers (as if being a creator), may experience the
outer world as a fi gment of his own imagination (the
world becomes mind-dependent), and the patient may
feel an experiential access to his own mind’s constitutive
capacities (experiential access to his ‘cognitive uncon-
scious’).
5.1 Primary Self-Reference Phenomena (C.1.17)
The subject senses an immediate link between himself
and external events or other people, a link that is not ex-
plained or mediated by a preexisting paranoid attitude,
feelings of insuffi ciency, preceding panic attack or depres-
sive guilt. In other words, we are dealing here with pri-
mary self-reference phenomena that cannot be further psy-
chologically reduced (i.e. explained in terms of other
mechanisms).
Examples
At a party everything seemed to him to originate from him or
depend on him.
As she saw a group of passengers getting off the bus she had a
feeling that they were performing some sort of parody of her
actual state.
When he was having a cup of coffee, he thought that the clouds
resembled a man having a cup of coffee.
5.2 Feeling of Centrality
Fleeting feelings as if being the center of the universe.
Example
A former doctor recalled that when working in a small provin-
cial hospital, he sometimes had a transient ‘as if’ sentiment that
he was the only true doctor in the entire world and the fate of
humanity depended on him.
5.3 Feeling as if the Subject’s Experiential Field Is
Only Extant Reality
Example
A patient had sometimes a fl eeting feeling as if only objects in
his visual fi eld existed. Other people and places did not seem to
exist. He immediately considered it as nonsense.
5.4 ‘As if’ Feelings of Extraordinary Creative Power,
Extraordinary Insight into Hidden Dimensions of
Reality, or Extraordinary Insight into Own Mind or
the Mind of Others
5.5 ‘As if’ Feeling that the Experienced World Is Not
Truly Real, Existing, as if It Was Only Somehow
Apparent, Illusory, or Deceptive
Examples
He experiences other people as robots and everything as a big
pot of molecules, and then starts wondering if the world is real.
As a child she experienced that ‘the whole world was built up
just for her’, like a scene.
5.6 Magical Ideas (i.e. Ideas Implying Nonphysical
Causality), Linked to the Subject’s Way of
Experiencing (5.1–5.5)
Example
He had the impression as if he could control the weather, as it
seemed to change with his mood.
5.7 Existential or Intellectual Change
New or unusual preoccupation with existential, meta-
physical, religious, philosophical, or psychological themes.
Do not rate in case of hypomanic or manic states.
Frequently reported themes: supernatural phenome-
na; religion (especially Eastern); mystical experience; phi-
losophy; transcendental themes; meditation; psychology;
ancient rituals; symbols; reincarnation; the life to come;
struggle between good and evil; universal peace and com-
munication; meaning of existence; fate of the humanity;
salvation; alternative approaches to science; related ideas
about health and nutrition.
Parnas /Møller /Kircher /Thalbitzer/
Jansson/Handest/Zahavi
Psychopathology 2005;38:236–258
256
Examples
New ideas and interests that gradually overtook my life and
thinking absorbed me; they left a mark on my entire life.
Extremely occupied by thoughts about how to be good enough.
Had to redefi ne and analyze everything he was thinking about.
Needed new concepts for the world and human existence.
5.8 Solipsistic Grandiosity
The patient, in speech or behavior, exhibits a sense of
superiority over his fellow humans, typically associated
with his feelings of possessing extraordinary insights or
abilities (5.4). Others are seen as ignorant morons chasing
only material (superfi cial) aspects of existence. This at-
titude often has a slightly manneristic coloring.
References
Gross G, Huber G, Klosterkötter J, Linz M: Bonner
Skala für die Beurteilung von Basissymptomen.
Berlin, Springer, 1987 (Danish transl P Handest,
M Handest, Copenhagen, Synthélabo, 1995).
Handest P, Parnas J: Clinical characteristics of 50
rst-admitted ICD-10 schizotypal patients. Br
J Psychiatry 2005;187(suppl):49 –54.
Matthysse S, Holzman PS, Gusella JF, Levy DL,
Harte CB, Jørgensen Å, Møller L, Parnas J:
Linkage of eye movement dysfunction to chro-
mosome 6p in schizophrenia: additional evi-
dence. Am J Med Genet B Neuropsychiatr
Genet 2004; 128: 30–36.
Merleau-Ponty M: Phenomenology of Perception.
London, Routledge and Kegan, 1962.
Møller P, Husby R: The initial prodrome in schizo-
phrenia: searching for naturalistic core dimen-
sions of experience and behavior. Schizophr
Bull 2000; 26: 217–232.
Parnas J: Self and schizophrenia: a phenomeno-
logical perspective; in Kircher T, David A
(eds): The Self in Neuroscience and Psychiatry.
Cambridge, Cambridge University Press,
2003, pp 127–141.
Parnas J, Bovet P: Autism in schizophrenia revis-
ited. Compr Psychiatry 1991;
32: 1–15.
Parnas J, Cannon T, Jacobsen B, Schulsinger H,
Schulsinger F, Mednick SA: Life-time DSM-
IIIR diagnostic outcomes in offspring of
schizophrenic mothers: the results from the
Copenhagen High Risk Study. Arch Gen Psy-
chiatry 1993;
50: 707–714.
Parnas J, Handest P: Phenomenology of anoma-
lous self-experience in early schizophrenia.
Compr Psychiatry 2003; 44: 121–134.
Parnas J, Handest P, Sæbye D, Jansson L: Anoma-
lies of subjective experience in schizophrenia
and psychotic bipolar illness. Acta Psychiatr
Scand 2003; 108: 126–133.
Parnas J, Jansson L, Sass LA, Handest P: Self-ex-
perience in the prodromal phases of schizo-
phrenia: a pilot study of fi rst admissions. Neu-
rol Psychiatry Brain Res 1998;
6: 107–116.
Parnas J, Zahavi D: The role of phenomenology in
psychiatric classifi cation and diagnosis; in Maj
M, Gaebel W, Lopez-Ibor JJ, Sartorius N (eds):
Psychiatric Diagnosis and Classifi cation.
World Psychiatric Association’s Series on Evi-
dence and Experience in Psychiatry. Chiches-
ter, Wiley, 2002, pp 137–162.
Sass LA, Parnas J: Self, consciousness, and schizo-
phrenia. Schizophr Bull 2003;
29: 427–444.
Level of presence Score Present now, i.e.
2 weeks
Associated with
drug intake
Specifi c provoking
factors
Psychotic
elaboration
Absence
Questionably present
Mild
Moderate
Severe
Appendix A: EASE-rating criteria
Frequency/severity Score
Absence absence (defi nitely absent/ never experienced) 0
Questionably
present
perhaps experienced, but either recollected only at few occasions, or very dimly,
during the patient’s life (questionably present)
1
Present
Mild defi nitely experienced, at least three times in total (usually more frequently), but
at irregular occasions; the symptom does not constitute a major problem or source
of distress for the patient.
2
Moderate symptom is present either daily for extended periods of time (e.g. at least daily in
one week twice a year) or frequently but sporadically over at least 12 months
(may constitute a problem or a source of distress)
4
Severe almost constantly present (e.g. daily during recent 2 weeks); typically stressful,
source of suffering and dysfunction
5
Not scorable lack of info permitting to make a judgement blank
Examination of Anomalous
Self-Experience
Psychopathology 2005;38:236–258
257
Appendix B:
EASE Item Key List
1 Cognition and stream of consciousness
1.1 Thought interference
1.2 Loss of thought ipseity (‘Gedankenenteignung’)
1.3 Thought pressure
1.4 Thought block
1.4.1 Subtype 1: blocking
1.4.2 Subtype 2: fading
1.4.3 Subtype 3: combination
1.5 Silent thought echo
1.6 Ruminations-obsessions
1.6.1 Subtype 1: pure rumination
1.6.2 Subtype 2: secondary rumination
1.6.3 Subtype 3: true obsessions
1.6.4 Subtype 4: pseudo-obsessions
1.6.5 Subtype 5: rituals/compulsions
1.7 Perceptualization of inner speech or thought
1.7.1 Subtype 1: internalized
1.7.2 Subtype 2: equivalents
1.7.3 Subtype 3: internal as fi rst-rank symptom
1.7.4 Subtype 4: external
1.8 Spatialization of experience
1.9 Ambivalence
1.10 Inability to discriminate modalities of intentionality
1.11 Disturbance of thought initiative/intentionality
1.12 Attentional disturbances
1.12.1 Subtype 1: captivation by details
1.12.2 Subtype 2: inability to split attention
1.13 Disorder of short-term memory
1.14 Disturbance of time experience
1.14.1 Subtype 1: disturbance in subjective time
1.14.2 Subtype 2: disturbance in the existential time (temporality)
1.15 Discontinuous awareness of own action
1.16 Discordance between expression and expressed
1.17 Disturbance of expressive language function
2 Self-awareness and presence
2.1 Diminished sense of basic self
2.1.1 Subtype 1: early in life
2.1.2 Subtype 2: from adolescence
2.2 Distorted fi rst-person perspective
2.2.1 Subtype 1: mineness/subjecthood
2.2.2 Subtype 2: experiential distance
2.2.3 Subtype 3: spatialization of self
2.3 Psychic depersonalization (self-alienation)
2.3.1 Subtype 1: melancholiform depersonalization
2.3.2 Subtype 2: unspecifi ed depersonalization
2.4 Diminished presence
2.4.1 Subtype 1: not being affected
2.4.2 Subtype 2: distance to the world
2.4.3 Subtype 3: as subtype 2 plus derealization
2.5 Derealization
2.5.1 Subtype 1: fl uid global derealization
2.5.2 Subtype 2: intrusive derealization
2.6 Hyperrefl ectivity; increased refl ectivity
2.7 I-split (‘Ich-Spaltung’)
2.7.1 Subtype 1: I-split suspected
2.7.2 Subtype 2: ‘as if’ experience
2.7.3 Subtype 3: concrete spatialized experience
2.7.4 Subtype 4: delusional elaboration
2.8 Dissociative depersonalization
2.8.1 Subtype 1: ‘as if’ phenomenon
2.8.2 Subtype 2: dissociative visual hallucination
2.9 Identity confusion
2.10 Sense of change in relation to chronological age
2.11 Sense of change in relation to gender
2.11.1 Subtype 1: occasional fear of being homosexual
2.11.2 Subtype 2: a feeling as if being of the opposite sex
2.12 Loss of common sense/perplexity/lack of natural evidence
2.13 Anxiety
2.13.1 Subtype 1: panic attacks with autonomous symptoms
2.13.2 Subtype 2: psychic-mental anxiety
2.13.3 Subtype 3: phobic anxiety
2.13.4 Subtype 4: social anxiety
2.13.5 Subtype 5: diffuse, free-fl oating pervasive anxiety
2.13.6 Subtype 6: paranoid anxiety
2.14 Ontological anxiety
2.15 Diminished transparency of consciousness
2.16 Diminished initiative
2.17 Hypohedonia
2.18 Diminished vitality
2.18.1 Subtype 1: state-like
2.18.2 Subtype 2: trait-like
3 Bodily experiences
3.1 Morphological change
3.1.1 Subtype 1: sensation of change
3.1.2 Subtype 2: perception of change
3.2 Mirror-related phenomena
3.2.1 Subtype 1: search for change
3.2.2 Subtype 2: perception of change
3.2.3 Subtype 3: other phenomena
3.3 Somatic depersonalization (bodily estrangement)
3.4 Psychophysical misfi t and psychophysical split
3.5 Bodily disintegration
3.6 Spatialization (objectifi cation) of bodily experiences
3.7 Cenesthetic experiences
3.8 Motor disturbances
3.8.1 Subtype 1: pseudo-movements of the body
3.8.2 Subtype 2: motor interference
3.8.3 Subtype 3: motor blocking
3.8.4 Subtype 4: sense of motor paresis
3.8.5 Subtype 5: desautomation of movement
3.9 Mimetic experience
(resonance between own movement and others’ movements)
4 Demarcation/transitivism
4.1 Confusion with the other
4.2 Confusion with one’s own specular image
4.3 Threatening bodily contact and feelings of fusion with another
4.3.1 Subtype 1: feeling unpleasant, anxiety provoking
4.3.2 Subtype 2: feeling of disappearance, annihilation
4.4 Passivity mood (‘Beeinfl ussungsstimmung’)
4.5 Other transitivistic phenomena
5 Existential reorientation
5.1 Primary self-reference phenomena
5.2 Feeling of centrality
5.3 Feeling as if the subject’s experiential fi eld is the only extant
reality
5.4 ‘As if’ feelings of extraordinary creative power, extraordinary
insight into hidden dimensions of reality, or extraordinary insight
into own mind or the mind of others
5.5 ‘As if’ feeling that the experienced world is not truly real, existing,
as if it was only somehow apparent, illusory or deceptive
5.6 Magical ideas linked to the subject’s way of experiencing
5.7 Existential or intellectual change
5.8 Solipsistic grandiosity
Parnas /Møller /Kircher /Thalbitzer/
Jansson/Handest/Zahavi
Psychopathology 2005;38:236–258
258
Appendix C:
EASE/BSABS Comparison
EASE BSABS
1.1 Thought interference C.1.1
1.3 Thought pressure C.1.3
1.4 Thought block C.1.4
1.6.1 Pure rumination C.1.2 (partly)
1.6.2 Secondary rumination C.1.2 (partly)
1.6.3 True obsessions B.3.2 (partly)
1.6.4 Pseudo-obsessions B.3.2 (partly)
1.6.5 Rituals/compulsions B.3.2 (partly)
1.9 Ambivalence A.5
1.10 Inability to discriminate modalities of intentionality C.1.15/A.6.2 (partly)
1.11 Disturbance of thought initiative/intentionality C.1.13
1.12.1 Captivation by details C.2.9
1.12.2 Inability to split attention A.8.4
1.13 Disorder of short-term memory C.1.9
1.15 Discontinuous awareness of own action C.2.10
1.16 Discordance between expression and expressed A.7.2
1.17 Disturbance of expressive language function C.1.7
2.2.2 Experiential distance B.3.4 (partly)
2.3.2 Unspecifi ed depersonalization B.3.4 (partly)
2.4.1 Not being affected A.6.3 (partly)
2.5.1 Fluid global derealization C.2.11
2.5.2 Intrusive derealization C.2.11
2.6 Hyperrefl ectivity; increased refl ectivity B.3.1
2.13.2 Psychic-mental anxiety D.15 (partly)
2.13.3 Phobic anxiety B.3.3
2.16 Diminished initiative A.4
2.17 Hypohedonia A.6.3 (partly)
2.18.1 Diminished vitality state-like A.3.1 (partly)
2.18.2 Diminished vitality trait-like A.3.1 (partly)
3.1.1 Morphological change, sensation of change D.9
3.2.2 Mirror-related phenomena, perception of change C.2.3.6 (partly)
3.3 Somatic depersonalization D.1.1
3.7 Cenesthetic experiences D.1; D.3–9; D.11–14
3.8.1 Pseudo-movements of the body D.10
3.8.2 Motor interference C.3.1
3.8.3 Motor blocking C.3.2
3.8.4 Sense of motor paresis D.2
3.8.5 Desautomation of movement C.3.3
3.9 Mimetic experience C.2.3.7
5.1 Primary self-reference phenomena C.1.17
For the sake of completeness, it should be noted that there are certain natural overlaps
between EASE and BSABS items; yet defi nitions need not to be exactly identical. As a rule,
the EASE items are described in more phenomenological detail. For the purpose of com-
parison, the lists of items from both scales are presented. This permits assessment of sim-
ilarities between the studies using different instruments.
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The concept of autism is reviewed in its historical evolution. It is suggested that the Bleulerian insistence on the withdrawal component in autism contributed to the decline of its use in adult psychiatry. Phenomenology offers another approach to grasping the nature of autism as a relational (subject-outer world) phenomenon. European phenomenological psychiatry in the field of schizophrenia is introduced and its attempts to reveal the essence of autism are presented. Autism is here considered as a "loss of vital contact with reality" (Minkowski), "inconsistency of natural experience" (Binswanger), or "the global crisis of common sense" (Blankenburg). It is proposed that autism represents dysfunctional perceptual/expressive attunement to the outer world. The usefulness of this concept is briefly examined in relation to the diagnosis and etiopathogenesis of schizophrenia.
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