The overall aim of this study is to define the fundamental phenomenological pattern of the two body-affecting FRS. Through the lived body, the subject tacitly participates in the field of experience, interacts within the world [ 70 — 72 ] and also experiences himself as a bounded, temporally persistent entity [ 73 ].
Recent psychiatric research on individuals in the prodromal phase of schizophrenia has shown that fundamental disturbances of the lived body concerning the feeling of mineness may precede the development of more superficial positive symptoms such as FRS [ 74 ]. Therefore, our phenomenological explanation of the two FRS accounts for the relationship between disorders of pre-reflective self-experience and symptoms of acute schizophrenia [ 75 ]. Moreover, we describe the transition from non-psychotic anomalies of bodily experience to full-blown disorders of agency such as delusions of alien control.
In this article, we put forward the hypothesis that the aforementioned two FRS can be seen as expressions of a disturbance of intentionality and agency [ 76, pp. We also hypothesize that the two FRS are, although clinically different, interrelated and of a very similar phenomenological structure being rooted in the disorder of basic self-awareness. Since anomalous bodily experiences are considered to be potential markers of beginning schizophrenia [ 79 , 80 ], our study will help to better understand the experiential core gestalt of the prodromal phase of schizophrenia.
In this paper, we will present descriptions of schizophrenia patients with body-affecting FRS. Four patients described [ 58 , 75 ] in this paper were treated in the Department of General Psychiatry, University of Heidelberg. All patients underwent a comprehensive psychiatric evaluation. The EASE interview Examination of Anomalous Self-Experience focuses on a phenomenological assessment of altered self-experience with respect to five domains: 1 cognition and stream of consciousness, 2 self-awareness and sense of presence, 3 bodily experiences, 4 demarcation, and 5 existential orientation.
The main focus in our study lies on the bodily experience of these patients. In addition, all patients were thoroughly explored by two experienced psychiatrists D. In our study, we were mainly interested in the 1 st -person perspective and the form and structure of conscious experience. Moreover, our aim was to grasp the experiential framework of the two body-affecting FRS and to extract the four stages of their development.
We used word-by-word descriptions to understand the perspective and experience of patients with FRS. Besides the four patient vignettes from our own studies, we also searched for case reports describing schizophrenia patients with body-affecting FRS in the historical and modern psychiatric literature. We identified several descriptions illustrating fundamental disturbances of the self concerning the feeling of mineness and the sense of agency and body-affecting FRS in schizophrenia.
Therefore, both FRS will be presented in relation to the patient, his lived body, various modes of consciousness and engagement with the world. The structure of the FRS will be formalized and arranged into basic phenomenological categories such as basic and higher-level self-experience, embodiment, temporality, spatiality, intersubjectivity and, most of all, intentionality and sense of agency SA. In the sections above, all elements have been described that are needed to analyse the development of body-affecting FRS.
There are four stages that should be distinguished in principle see also [ 82 ] :. The first three levels illustrate the phenomenological characteristics that occur in the pre-psychotic phase of schizophrenia and in schizotypal disorders. The last stage describes the transition to full-blown psychosis. It is self-present and acts in the first person perspective. Such tacit experience is an essential presupposition for the subject to interact with his environment.
Now the prodromal phase of schizophrenia involves subtle, but often progressive alterations of such basic bodily experience, namely a profound disturbance of pre-reflective self-awareness or ipseity. From a phenomenological point of view, subjects in this state experience an existential insecurity and a diminished feeling of being a demarcated self:. The first patient is afraid of losing himself and becoming substantially different from the others.
The second patient describes a fragmentation of self-presence: On the one hand, he experiences a feeling of not being an embodied subject anymore; on the other, he observes his feelings more carefully than he did before. On the other hand they are missing an adequate control over these actions sense of agency.
The patients are no longer auto-affected to the same degree and therefore not able to perform their intentional bodily acts properly:. From a phenomenological point of view, in both cases 3 and 4 the movements are not embedded in basic self-experience anymore. The patients are slowed down and experience everyday actions as disintegrated and unreal.
They have to intensively concentrate on every single movement, because otherwise they would not be able to fulfill their intentions.
Thus, they illustrate the weakening of operative intentionality of movement, or the disturbance of the tacit dimension of experience. However, patients at this stage are still able to compensate for the disturbances through intensive self-monitoring. This phenomenon will be described in the next paragraph. The weakening of operative intentionality leads to an increasing gap between the two layers of intentional consciousness described above and to an increased self-monitoring.
There is a correlation between the decrease on the first-level pre-reflective self-awareness and the compensatory increase of activity on the second-level reflective self-consciousness. If bodily movements are not embedded in basic self-presence, patients begin to ponder intensively about each single action. Four prodromal patients who later developed schizophrenia reported disturbances of their motor functions:. In these cases we face a weakness of operative intentionality on the one hand, and an objectification of bodily movements on the other.
These patients are unable to realize their bodily intentions in a synchronized way. The bodily actions are not constituted as a whole, but rather pieced together as successions of singular, fragmented movements. The link between basic self-awareness and the tacit intentionality of movement is disrupted.
As a result of this disconnection, the patients are not able to initiate, plan and structure their directed bodily actions coherently anymore. The normally automatic intentional acts are not tacit and unquestioned anymore; they become apparent, hypersignificant and spatialized. Phenomenologically, it is a central property of the second-level self-consciousness to enable the thematization and thus objectification of experiences such as the act of perception or an affective quality thereof.
They are turned into fragmented entities that need to be dealt with individually in order to create meaningful sequences of action or perception. The next stage is reached when the gap between the two layers of intentionality amounts to a disconnection of the first-level pre-reflective bodily self-awareness and the second-level reflective self-consciousness.
The patients lose the tacit form of acting and their bodies do not serve as a medium for interacting within the world anymore.
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In parallel to this development, the pre-reflective SA linked to the implicit experience of bodily actions separates from the higher-order SA linked to the conscious attribution of movement. In fact, patients experience the beginning of a change in the structure of their intentional bodily acts. This progression ends in a state where all automatic performances become explicitand disintegrated.
According to Stanghellini [ 57 ], patients at this stage do not experience intentional acts such as movements as their own, i. They often describe themselves as deanimated bodies 'cyborgs' or disembodied spirits 'scanners'. Schizophrenia patients who in this way feel like a cyborg said:.
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In both cases, the tacit, automatically synthesized unity of body and mind is interrupted, leading to a feeling of inanimateness [ 57 ]. Consequently, the patient experiences his bodily perceptions and movements as alienated:. From a phenomenological point of view, both patients suffer from a disembodiment [ 6 , 57 , 74 ] of the active-explicit intentionality of bodily movement. Patients then often experience themselves as robots or human machines, or they become passive spectators of their body, thus showing a 'Cartesian' separation of the body and mind.
The concept of the reification of the human body and mind was first introduced and described by Descartes in the early 17 th century. He conceived of the human body as a mechanical apparatus and explained its functions using physical, chemical and materialist vocabulary [ 58 , 85 , 86 ]. At this stage, directed bodily movements lose their automaticity and transparency. Moreover, the patients suffer a loss of the sense of bodily agency.
However, she is not yet convinced that this might actually be true.
Impulses and motor actions are no longer experienced as self-generated, but as made impulses and experiences. Their intentional impulses and bodily movements are now reversed and directed towards them from an external agent. At this stage, a definite transition into psychosis and FRS occurs. All three patients experience alienation of their own bodily movements. They suffer from a profound change in the phenomenological structure of their experience. It feels like being far away from the lived body. The synthesis of the initiative to eat, to work or talk to somebody and the corresponding bodily action moving the jaw, arms or tongue is not achieved.
The intentional arc which normally connects both components is torn apart, and they seem to exist independently of each other. As a result, the patients experience their bodily actions as initiated by an external agent. As a result, the form of the self-experience affects the change in content e. In the case of made impulses, they experience a sudden drive to carry out some action as coming from the outside. Thus, both bodily drives and movements may appear as externalized and manipulated.
However, this other subjectivity is still hidden, beyond recognition. In other cases with flamboyant psychotic symptoms, patients refer to an identifiable source of "made" acts case and "made" impulses case 7 :. Not until this particular stage of the illness, the phenomenological and clinical distinction between made impulses and made volitional acts is possible: According to Gallagher [ 64 ], the first three patients experience the SA on both levels as alienated and externalised.
The last patient, however, experiences an impulse to empty the urine bottle. He recognizes himself as being the agent of the sudden behavior. On the other side, he feels being driven from outside to do so. Pointing to the distinction between SO and SA, the last patient suffers from alienation and externalisation of SA as higher-order experience that is linked to the attribution of agency. Although made from outside, he is still able to reflect on his action and recognizes it as his own. More precisely, in this case, SO remains complete extant. Although similar in content, case and case illustrate different subsets of the psychotic process leading to full-blown psychosis and FRS.
Taken together, however, all four patients are unable to actively intend their bodily actions; rather, they are passively moved and pushed to realize motor activities by an external force. Instead of acting, they feel acted upon. The manipulating agent is not hidden anymore, but gains a concrete, though technical form such as a computer, cosmic strings or an X-ray department.
In some cases, there is even a personalized agent [ 11 ]. At this stage of the illness, patients experience full-blown schizophrenic symptoms, like FRS. Parallel with motoric fragmentation and hyperreflexivity, drives to carry out actions and bodily movements become disembodied, alienated and finally externalised. The patients lose control over their body, and its actions now emanate from an external power. This paper aimed at investigating the self-experience of schizophrenia patients with body-affecting Schneiderian FRS.
We have also been looking for the fundamental pattern that characterizes the subjectivity of schizophrenia patients with particular FRS. Two main findings emerged: 1 The subjective experience of made volitional acts and made impulses in schizophrenia is based on a fundamental transformation of both levels of intentionality and sense of agency 2. The above mentioned two FRS are, although clinically very different, of a similar phenomenological structure. Since the past decade, there is growing empirical evidence that disorders of basic self-awareness are a core feature of schizophrenia spectrum disorders [ 80 , 92 — 94 ].
We showed that non-psychotic anomalous bodily experiences are rooted in the weakness of operative intentionality. However, only by disembodiment, alienation and finally externalisation of agency the final transition to full-blown psychotic symptoms such as FRS or delusions of alien control occurs. Keeping this psychopathological trajectory in mind, we conclude that the above mentioned FRS are based on a transformation of both levels of intentionality and agency; they should therefore be strongly considered as pathognomonic for the diagnosis of schizophrenia.
FRS [ 95 ]. Second, in contrast to operationalized approaches, the phenomenological method is person-centered and emphasizes an authentic and patient-friendly examination of anomalous subjective experience, in spite of the stressful situation it may cause. In fact, the phenomenological approach to interviewing might help to improve patient compliance and thereby positively influence the course of the disease. Third, phenomenological psychopathology has the potential to overcome the Cartesian dualism of mind-versus-body and mind-versus-world still prevalent in daily clinical routine.
Fourth, the implementation of phenomenological approaches for studying particular psychotic symptoms can contribute to bridging the explanatory gap between clinical symptoms and current neurobiological models as exemplified by recent studies [ 96 , 97 ]. Fifth, phenomenological accounts of psychotic experience might complement the psychotherapeutic treatment of schizophrenia patients by providing novel strategies to strengthen pre-reflective self-awareness [ 98 ].
We acknowledge potential limitations of the phenomenological method in general and our qualitative study of FRS in particular 1. In addition, patients might be suspicious, indifferent and not willing to speak about their private and often embarrassing experiences 3. The clinical presentation and the statements which the interviewer is confronted with might be interpreted in different ways e. A precise phenomenological exploration requires clinical expertise, time, effort and skill to empathize with the interviewee 5.
Last but not least, patients suffering from disorders of pre-reflective self-awareness might have difficulties to articulate their experiences [ 74 , 99 ]. Here, a phenomenologically informed vocabulary could also help patients to arrive at a more detailed and accurate description of their condition. It is a well-known fact that the clinical distinction between acute psychotic experience in schizophrenia and bipolar or manic disorders in which patients might exhibit risky behavior is very difficult.
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Ethical view upon the human situation within the "unity-of-everything-there-is-alive". Theories of nature and education in the development of the human self in the eighteenth century. The educational aspect of the primordial situation of one's being-in-the-world. Sensuous experience and transcendental empiricism f. Brentano, e. Husserl, P. Husserl's phenomenological analysis of ethics as a foundation for pedagogy. Enlightenment, humanization, and beauty in the light of Schiller's "letters on the aesthetic education of man". Historical and contemporary virtues as reflected in Chinese literatre.
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