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Comprehensive Psychiatry 65 (2016) 44 49

Anomalous self-experiences and their relationship with symptoms,

neuro-cognition, and functioning in at-risk adolescents and young adults
Anna Comparelli a,, Valentina Corigliano a , Antonella De Carolis b , Daniela Pucci a ,
Massimiliano Angelone c , Simone Di Pietro a , Giorgio D. Kotzalidis a , Laura Terzariol d ,
Luigi Manni d , Alberto Trisolini d , Paolo Girardi a
Sapienza UniversityRome, School of Medicine and Psychology, NESMOS Department (Neurosciences, Mental Health and Sense Organs), and Unit of Psychiatry,
SantAndrea Hospital, Rome, Italy
Sapienza UniversityRome, School of Medicine and Psychology, NESMOS Department (Neurosciences, Mental Health and Sense Organs), and Unit of Neurology,
SantAndrea Hospital, Rome, Italy
Residential Care Home San Raffaele, Unit of Psychiatry, Montecompatri, Rome, Italy
Department of Mental Health, ASL of Viterbo, Italy


Empirical and theoretical studies support the notion that anomalous self-experience (ASE) may constitute a phenotypic aspect of vulnerability to
schizophrenia, but there are no studies examining the relationship of ASE with other clinical risk factors in a sample of ultra-high risk (UHR)
subjects. The aim of the present study was to explore the relationship between ASE, prodromal symptoms, neurocognition, and global functioning
in a sample of 45 UHR adolescents and young adults (age range 1525 years) at first contact with Public Mental Health Services. Prodromal
symptoms and global functioning were assessed through the SIPS interview. ASE was evaluated through the Examination of Anomalous
Self-Experience (EASE); for neurocognition, we utilized a battery of tests examining seven cognitive domains as recommended by the
Measurement And Treatment Research to Improve Cognition in Schizophrenia.
In the UHR group, higher levels in two domains of the EASE (stream of consciousness and self-awareness) were found in comparison
with help-seeking subjects. Correlational analysis corrected for possible confounding variables showed a strong association (p N 0.001)
between higher EASE scores and global functioning. A principal factor analysis with Varimax rotation yielded a two-factor solution, jointly
accounting for 70.58% of the total variance in the UHR sample. The first factor was comprised of SOPS domains, while the second was
comprised of EASE-total, EASE-10, and GAF variables. Our findings provide support for the notion that disorders of self-experience are
present early in schizophrenia and are related to global functioning. As such, they may constitute a potential marker of risk supplementing the
UHR approach.
2015 Elsevier Inc. All rights reserved.

1. Introduction attenuated or brief self-limited psychotic symptoms, the first

episode of psychosis is generally preceded by a prodromal
In schizophrenia, the development of standardized assess- phase that is characterized by non-specific negative symptoms,
ment instruments and specific criteria defining the so-called difficulty in social and age-appropriate role functioning,
ultra-high risk (UHR) paradigm [1] with good predictive self-experienced cognitive symptoms, and impaired neuro-
validity has encouraged research on early detection and and social cognition.
establishment of early recognition and intervention worldwide. Although the UHR approach has shown diagnostic validity
The resulting perspective research has confirmed that, as well as and feasibility of prospective ascertainment of individuals at
risk for psychosis [2,3] and provided a platform for studies
assessing the risks and benefits of early interventions [4,5],
Corresponding author at: NESMOS Department, Sapienza University,
there is a wide consensus that it suffers from several conceptual
2nd Medical School, SantAndrea Hospital, Via di Grottarossa 1035-1039, and methodological shortcomings that need to be addressed in
00189 Rome, Italy. Tel. +39 0633775664; fax: +39 0633775342. order to improve its scientific and clinical utility. In fact, UHR
E-mail address: (A. Comparelli). predictive criteria, which use increasing intensity of positive
0010-440X/ 2015 Elsevier Inc. All rights reserved.
A. Comparelli et al. / Comprehensive Psychiatry 65 (2016) 4449 45

psychotic symptoms to predict psychosis, in contrast to a Table 1

comprehensive psychopathological theory about the nature of Demographic and psychopathological features of the sample.
psychosis, are rather limited in their informative value about UHR(45) HS (70) P value
the phenotypic markers of vulnerability for psychosis. (SE) (SE)
Moreover, there is a large body of evidence that calls into Age 21.04 (0.4) 20.63 (0.3) 0.4
question the specificity of attenuated psychotic symptoms, Sex (Males) 22 (48.9%) 42 (60%) 0.2
Education 12.40 (0.3) 11.00 (0.3) 0.009
which are quite common in a broad range of non-psychotic
Unusual Thought Content (SOPS P1) 2.76 (0.1) 1.11 (0.1) b0.001
psychiatric conditions [6] and even in the general population Suspiciousness (SOPS P2) 2.09 (0.2) 1.46 (0.1) 0.02
[7]. Addressing these problems has become increasingly Grandiosity (SOPS P3) .91 (0.2) .43 (0.1) 0.08
important in light of the reducing rates of transition to Perceptual Abnormalities (SOPS P4) 1.09 (0.2) 0.71 (0.1) 0.2
psychosis and growing number of false positives in more Disorganized Communication (SOPS P5) 1.09 (0.2) .40 (0.1) 0.01
EASE 1 19.02 (2.0) 9.03 (1.1) b0.001
recent UHR cohorts [8].
EASE 2 24.73 (1.9) 14.73 (1.4) b0.001
Empirical and theoretical studies support the notion that EASE 3 2.64 (0.5) 2.12 (0.3) 0.04
anomalous self-experience (ASE) may constitute a phenotypic EASE 4 1.71 (0.4) .88 (0.2) 0.08
aspect of vulnerability to schizophrenia [9]. Recent prospective EASE 5 3.04 (0.6) 1.91 (0.6) 0.2
findings suggest that identifying ASE in a UHR population EASE total 51.09 (4.4) 28.67 (4.6) 0.001
EASE 10 subscale 12.3 (1.4) 6.8 (6.9) 0.02
may provide a means of further closing in on individuals who
Diagnosis (DSM-IV)
are truly at high risk of psychotic disorders, and particularly of Anxiety Disorders 10 18
schizophrenia spectrum disorders [10]. However, there are Relational Problems 5 17
currently no empirical data that elucidate how UHR criteria and Personality Disorders 12 16
ASE might differentially characterize the risk for psychosis. Adjusting Disorders 1 9
Affective Disorders 16 7
In this study, we examined the relationship between ASE
Eating Disorders 1 3
and other clinical risk factors for psychosis. More specifically,
our aims were: (1) to compare the prevalence and nature of
ASE between a group of non-psychotic, help-seeking neurological disorders; (5) current drug abuse. Of the 159
adolescents and young adults and a group of UHR subjects; subjects initially screened, 39 were excluded for current
(2) to examine the relationship between ASE and other risk substance abuse, 11 presented a diagnosis of current or past
factors such as prodromal negative, disorganized and general psychosis and 4 presented with severe medical conditions,
symptoms, global functioning, and neurocognitive impairment neurological disease, or past diagnosis of developmental
in a group of UHR patients; (3) to examine the mutual disorder. Forty-five patients met the criteria for psychosis risk
relationships between ASE and the domains of clinical risk syndrome according to McGlashan et al. [11], based on the
encompassed in the UHR paradigm. In this way, we expect to presence of Attenuated Psychotic Symptoms (APS), Brief
improve the informative value of the phenotypic markers for Intermittent Psychotic Symptoms (BIPS), or functional decline
vulnerability to psychosis. and family history of schizophrenia or Schizotypal Personality
Disorder (Genetic Risk and Deterioration, GRD). The UHR
group was stratified as follows: 35 (78%) in the APS group,
2. Materials and methods 4 (9%) in the GRD group, 1 (2%) in the BLIPS group, and
2.1. Subjects 5 (11%) in both the APS and the GRD groups. Based on the
Structured Interview for DSM-IV Disorders-I (SCID-I) [12],
The population recruited for this study included 159 patients met the diagnoses shown in Table 1. Patients were free
adolescents and young adults who consecutively came to seek from any psychotropic medication at the time of first
help for emotional and behavioral difficulties in two clinical evaluation. All participants (or a stable guardian for minors)
outpatient settings: (1) the Outpatient Clinic for Psychosis provided informed consent for participation in the study and
Prevention at SantAndrea Hospital in Rome; (2) the publication of results. The research was approved by the local
Adolescent Care Unit at the Mental Health Service of Viterbo. Ethics Committee.
Data were collected as part of an ongoing prospective clinical
trial on prevention of mental health disorders.
2.2. Assessment
Enrolled patients met all of the following criteria: (1) first
contact with the mental health service; (2) age between 15 2.2.1. Psychopathology
and 25 years; (3) a level of understanding that was sufficient Data on socio-demographic and psychopathological
to communicate with investigators and to understand the variables were collected at clinical interview. Criteria for
nature of the study. prodromal syndrome were determined using the Italian
Exclusion criteria included: (1) current or past diagnosis of version of the Structured Interview for Psychosis Risk
psychosis; (2) comorbid or past diagnosis of autistic disorder Syndrome (SIPS) [13,14], including the Scale of Prodromal
or other pervasive developmental disorder; (3) history of Symptoms (SOPS). The SIPS also includes the Global
severe head injury; (4) severe medical conditions or major Assessment of Functioning (GAF) scale, used to determine
46 A. Comparelli et al. / Comprehensive Psychiatry 65 (2016) 4449

the general level of current functioning and functional Table 2

deterioration, which is operationally defined as a 30% or Neuropsychological test battery according to the domains of the Measurement
and Treatment Research to Improve Cognition in Schizophrenia.
greater decrease in the GAF score during the last 12 months.
The raters (A.C. and V.C.) are expert clinicians trained in the Cognitive domain Variables
administration of the SIPS/SOPS. Cohen's for inter-rater Speed of processing
reliability was 0.85. Trail Making Test-A subtest (TM A) 1. time in seconds
(nonverbal) [32]
For qualitative and quantitative semi-structured phenome-
Stroop Word Test (Stroop W): word 2. number of words read correctly
nological exploration of ASE the Italian version of Examination reading (verbal) [33] in 30 s
of Anomalous Self- Experience (EASE) [15] was used. The Verbal Phonemic Fluency (all words 3. sum of words produced in 60 s
EASE [16] consists of 57 main items and explores five starting with F, P, and L) [34]
overlapping domains of experience: (1) stream of conscious- Sustained attention/vigilance
Wisconsin Card Sorting Test 4. number of non perseverative
ness; (2) sense of presence/basic identity; (3) bodily experience;
(WCST) [35] errors (NPEs)
(4) sense of demarcation; (5) existential reorientation and Working memory
solipsistic experiences. The raters (M.A. and S.D.P.) are expert Corsi block test: spatial span [36] 5. raw score correct
clinicians trained in the administration of the EASE. Cohen's Trail Making B-A subtest 6. differential score between
for inter-rater reliability was 0.78. (TM B-A) [32] subtests B and A
(time in seconds)
According to Koren et al. [17], for our analysis we selected
Verbal learning
10 EASE items (EASE-10) that reflect most prototypically the Buschke Verbal Selective Reminding 7. delayed recall 15 min after
disorders of self-experience. These comprised: (1) hyper- Test (BVSRT) [37] 6 learning trials
reflectivity; (2) loss of common sense/perplexity; (3) mirror- Visual learning
related phenomena; (4) loss of thought ipseity (i.e. directly ReyOsterrieth Complex Figure 8. delayed recall after 15 min
(ROCF) [38]
given, pre-reflective sense of mineness); (5) spatialization of
Reasoning and problem solving
experience; (6) ambivalence; (7) diminished sense of basic WCST [35] 9. number of completed
self; (8) loss of first person perspective; (9) perceptualization categories (CCs)
of inner speech; and (10) thought pressure. Raven's Colored Progressive 10. number of correct answers
Matrices (RCPM) [21]
Social cognition
2.2.2. Neuropsychological measures Facial Affect Recognition (FAR): 11. sums of named (subtest A)
In the UHR group, neuropsychological assessment was photographs of emotional faces and and recognized
carried out according to the recommendations of the emotion labels were presented on a (subtest B) emotions
Measurement And Treatment Research to Improve Cogni- computer screen. Participants were
asked to choose 1 of 6 emotions
tion in Schizophrenia (MATRICS) [18,19], including the
explicitly specified on the monitor
exploration of seven domains, e.g. speed of processing, for a given face (subtest A) or to
sustained attention/vigilance, working memory, verbal select 1 of 6 faces that corresponded
learning, visual learning, reasoning/problem-solving, and to the emotion displayed
social cognition [20]. The tests used and the parameters (subtest B) [39]
considered for each domain are described in Table 2. Current
IQ was estimated using Raven's Standard Progressive
Matrices [21]. Minimum initial eigenvalues 1.0 and reliability (Cronbachs
alpha) of factors N0.7 were the criteria used to determine the
2.3. Statistical analysis number of factors retained in each model. To be included in
a given factor, an item had to possess a factor loading N0.50
Differences between UHR and HS patients in socio- in its factor. A factor, to qualify as such, had to possess an
demographic and psychopathological features were analyzed eigenvalue N N 1. A significance level of 0.05 was used for all
using a t-test for independent samples (pretesting for homoge- statistical tests, and two-tailed tests were applied. Tests were
neity of variance). In the UHR subgroup, we correlated the carried out using the Statistical Package for Social Sciences
EASE-total and EASE-10 scores with SOPS positive, negative, software program version 17.0.1 (SPSS Inc. Chicago, IL).
disorganized, and general subscale scores, with neurocognitive
domain z-scores, and with global functioning. Correlations were
corrected for possible confounding variables (age, years of 3. Results
education, and IQ). A Bonferroni correction was performed on
the multiple correlational analysis. Finally, the mutual relation- Data on socio-demographic and psychopathological
ships between all domains of clinical risk were assessed using (SOPS and EASE) features of the sample are presented in
an exploratory principal component analysis (PCA) with a Table 1. Prodromal patients and HS subjects did not differ
Varimax rotation. Seven variables were entered in the PCA for sex and age, whereas years of education were
(SOPS Pos, SOPS Neg, SOPS Dis, SOPS Gen, EASE-total, significantly higher in the UHR group. As expected, the
EASE-10, GAF). two subgroups differed significantly for SOPS items P1, P2,
A. Comparelli et al. / Comprehensive Psychiatry 65 (2016) 4449 47

Table 3
Correlation between Anomalous Self-Experiences and psychopathology, functioning and neuropsychological domains and in the UHR sample.
EASE-total .485 .049 .139 .137 .602 253 .124 .287 .049 .094 .357 .043
EASE-10 .182 .064 .044 .013 .599 .077 .247 .202 .131 .006 .250 .151
SP: Speed of Processing; WM: Working Memory; SA: Sustained Attention; VeL: Verbal Learning; ViL: Visual Learning; R&PS: Reasoning and Problem
Solving; SC: Social Cognition.
p b 0.05.
p b 0.001.

and P5. The level of ASE was significantly higher in the The two groups differed for being or not at risk for an
UHR group than in HS-non UHR subjects for EASE impending psychosis.
domains 1 and 2, EASE-total score, and the EASE-10 As expected, ASE was present in the entire sample, but in
subscale. In the UHR subgroup, the mean IQ and GAF the UHR group scores were significantly higher in the first and
scores were 99.42 (SD = 7.75) and 57.75 (SD = 8.11), second domains of EASE, i.e. stream of consciousness and
respectively. Among UHR subjects, partial correlations self-awareness. Nelson et al. [10] showed that the level of all
between ASE domains and psychopathological features EASE domains was significantly higher in a group of UHR
showed that higher EASE total score correlated with higher subjects compared with healthy volunteers; interestingly, in
SOPS Positive score (p b 0.05); higher EASE total and the same study, stream of consciousness, and self-awareness
EASE-10 scores were correlated with a lower GAF score predicted the onset of illness over a mean follow-up of
(p b 0.001). No significant correlations were found between 1.5 years in the UHR group.
EASE total and EASE 10 scores and neuropsychological In agreement with previous reports, these results provide
measures (Table 3). After Bonferroni correction (all further support for the notion that disorders of self-experience
p b 0.001), only the association between EASE-total and are present early in the illness and, as such, may constitute a
EASE-10 scores with the GAF score retained statistical potential marker of risk supplementing the UHR approach.
significance. Since ASE, as a possible phenotypic precursor of schizophrenia,
The factorial analysis of prodromal symptoms, ASE, and is qualitatively different from subthreshold psychosis, it may
functioning yielded a two-factor solution, jointly accounting have the potential to introduce further specificity into current
for 70.58% of the total variance in the entire sample. The first high-risk identification strategies. This hypothesis is also
factor was comprised of SOPS domains, and was thus termed advanced by Koren et al. [17] who proposed that ASE is a
prodromal symptoms. The second factor was comprised of trait-marker and predicts schizophrenia or schizotypy, whereas
EASE-total, EASE-10, and GAF variables, and was termed prodromal symptoms are general markers of psychosis (across
ASE/functioning (Table 4). diagnostic categories). In this view, our study may be
considered an extension of the previous cited report [17].
The second and most important finding of the present study
4. Discussion is that in the UHR group higher levels of ASE are associated
with lower global functioning. This result is strongly confirmed
The first aim of this study was to compare the level of by both statistical and factor analyses. In the literature, there are
ASE in two groups of help-seeking adolescents and young two studies exploring this relationship, even if in quite different
adults at their first admission to public psychiatric services. cohorts. The first [17] examined this relationship in a sample of
help-seekers and found a relationship between EASE-10 and
Table 4 total scores with social and role functioning measures; the
Factor analysis. second study [22] showed that high levels of ASE were
Component significantly associated with poorer social functioning in the
1 2 early phases of schizophrenia and psychotic bipolar disorder
regardless of diagnosis. Of note, Velthorst et al. [23]
SOPS Pos .697 .433
SOPS Neg .800 .061 demonstrated that transition to psychosis in UHR patients is
SOPS Dis .888 .013 strongly predicted by lower global functioning scores as
SOPS Gen .678 .103 measured by the GAF. Consistent with other reports [24,25] it
EASE-total .108 .938 has been shown that level of functioning, as measured by the
EASE-10 .130 .906
GAF, improved with symptomatic remission in false positive
GAF .472 .644
UHR. Such a phenomenon may be highly improbable in
Extraction method: principal component analysis. Rotation method: subjects that are at true UHR for psychosis, as decreased levels
Varimax with Kaiser normalization.
Primary loadings are in bold typeface.
of functioning have been a persistent core phenomenon along
Explained variance (extraction sums of squared loadings): the entire prodrome of at-risk subjects who later converted to
Whole sample: Total = 70.58% (factor 1 = 37.49%; factor 2 = 33.09%). psychosis [26].
48 A. Comparelli et al. / Comprehensive Psychiatry 65 (2016) 4449

On the whole, our findings appear to be in agreement with research may indicate the specific role of clinical risk
the hypothesis of Koren et al. [17], suggesting that in UHR markers in prediction of long-term outcome.
subjects the presence of self-disturbances, with concomitant
low functioning, may represent a more specific, even if less
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