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Self-Disorder in Schizophrenia (2) - Revision CLEAN
Self-Disorder in Schizophrenia (2) - Revision CLEAN
*Corresponding author: Prof Louis Sass, Dept of Clinical Psychology, Graduate School of
Applied and Professional Psychology, Rutgers University, 152 Frelinghuysen Road, Piscataway,
New Jersey, USA 08854. Telephone: 917 513-9798. Email: lsass@rutgers.edu.
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Abstract
A growing body of research supports the role of self-disorders as core phenotypic features of
experience whose theoretical understanding continues to present a challenge. This is the second
of two articles that aim to clarify the nature of self-disorders in schizophrenia by considering the
overview of this model and critically assessed its descriptive adequacy with respect to the
considering how hyperreflexivity might form the crucial common thread or generating factor that
unifies the heterogeneous, and sometimes even contradictory features of schizophrenic self-
disorders. We outline implications of our revised model (IDMrevised) for explanatory research,
hyperreflexivity; revision.
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Introduction
In our first article, we drew attention to the substantial heterogeneity and variability that
involve not only the oft-noted diminished self-presence in which patients lose the sense of being
the subject or agent of their own experiences or actions, but also increased self-presence, as
when patients feel they are the sole constituting witness, central figure, or prime target of all that
occurs. We noted as well that the field of awareness—the lived world of objects, people, and
fragmented, random, and uncertain (decreased ‘grip’); but also as hyper-organized or hyper-
determined, often in a typically grandiose/paranoid manner, such that nothing seems accidental
and everything appears “just so” or as somehow oriented toward or referring to the patient
These contradictory aspects may not only succeed each other but can sometimes even co-
exist. Their prominence clearly requires revision of the current self-disturbance or ipseity-
disturbance model (IDM)1-3, which specifies only diminished self-presence while also conceiving
‘disturbed grip’ only as diminished grip. In article 1, we suggested the broader notions of altered
self-presence and altered grip/hold, aimed at recognizing that both these dimensions of
awareness can vary toward either diminishment or exaggeration, and that such variation may
occur across subgroups of patients or phases of illness, but also as more moment-to-moment
In this second article, our aim is to go beyond these more descriptive issues by focusing
on the theoretical question of how a revised IDM-model can account for these diverse
manifestations. According to the revised model we will propose, it is preferable to focus on what
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the different manifestations of schizophrenic self-disorders may have in common rather than on
what they purportedly lack. More precisely, we will argue that what the diverse expressions of
schizophrenic self-disorders share is not best conceived as the absence of something that,
minimal self or self-presence. The shared factor is better conceived as the presence of something
inwardness, and passivization. The self-disturbance model should be re-configured around the
concept of hyperreflexivity.
We will argue for this in two main ways. In the next section, we note difficulties inherent
to the concept of minimal or basic self as well as in its application to schizophrenic self-
disorders. Here we include a brief review of alternative proposals regarding the presumed
essence of self-disorders. In the next several sections, we explain how hyperreflexivity could
serve as a central common thread or generating factor able to unify—and in a sense, to explain 4
our proposal.
take on various forms and qualities. Beyond this heterogeneity and variability, a more general
regarding what kind, level, or aspect of ‘self’ is affected in self-disorders; in what sense it is
possible for core ‘selfhood’ to be considered disturbed; and whether a felt sense of self actually is
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a (necessary or regular) feature of ordinary experience (for reviews, see 5-6; for various proposals,
A first issue concerns the seeming contradiction between the supposedly ‘essential’ or
‘universal’ nature of minimal self in human consciousness and its proposed alteration or
disturbance in schizophrenic self-disorders. As discussed (cf. article 1), the IDM’s concept of
minimal self refers not to some contingent quality that only some experiences would possess, but
wonder, however, how this supposedly inalienable character of minimal self could be consistent
with the IDM’s account of self-disorders. How, or in what sense, could self-disorders involve a
disturbance of minimal self if the latter is also assumed to be necessarily preserved throughout
One response7 consists of arguing that self-disorders do still involve a disturbance at the
level of minimal self, but that the latter would somehow be merely ‘eroded’ or ‘diminished’
instead of being entirely absent. This solution can seem rather ad-hoc (and in fact was proposed
only after problems with the original model were noted). It would seem, in any case, that such a
self is actually defined and understood in the phenomenological literature (see 11-12; cf. article 1).
There the ‘mineness’ of experience is not established by reference to feelings of greater or lesser
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intensity but argued for as a logical necessity; and it is difficult to see how it could allow of being
conceived in terms of degrees. As Henriksen et al. 7 point out, even for patients with severe self-
disorders, there is not (and on theoretical grounds, could not be) any relevant doubt about who is
experiencing their symptoms. “[E]ven the pathological experiences under consideration,” writes
Another common strategy to address this problem has been to introduce a finer
eroded or disturbed in schizophrenic self-disorders. While various proposals exist (e.g. 13-14), the
most prominent distinguishes between the mineness of ‘ownership’ versus of ‘agency’, and
The main problem with this account is that many of our ordinary or somewhat
obsessional thoughts also come unbidden and without a sense of agency, simply crossing one’s
mind, and may even be experienced as imposed and intrusive, yet do not carry the sense or
quality of alienation as found in self-disorders. 15 There is also the fact that schizophrenic loss of
self can pertain not only to such activities as thinking or moving one’s arm—which do have an at
least potentially agentic quality—but also to states and feelings that would normally be passively
enjoyed or endured, such as emotions and sensations: What is altered in these latter experiences
It should be noted, as well, that even the underlying assumption—the idea that a
prereflective sense of self necessarily imbues ordinary conscious experience—is itself not
uncontested.16-18
Some theorists18-19 have, in fact, argued that pre-reflective experience is often and perhaps
typically transparent and impersonal, devoid of any form of self-awareness—as for example,
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when we are fully immersed and unreflectively engaged in activities. Still others 20 propose a
more open view regarding pre-reflective consciousness, allowing for different shades or degrees
of self-awareness in diverse situations or activities (e.g., contrast the self-aware quality of social
anxiety with the mindless absorption of the long-distance driver). Both views (whether
would seem inconsistent with the notion that schizophrenic self-disorders involve loss of some
We see, then, that there are problems with the notion of diminished minimal self as
currently formulated. Though clearly an important symptom, it is not a constant one nor can it
serve as a defining feature of schizophrenia. This is due not only to the importance of antithetical
forms of exaggerated self-presence or “for-me-ness” (cf. article 1), but also (as just noted) to
One may speak of alterations or anomalies of self-presence as key factors, but only so
long as one recognizes that these disturbances can deviate in opposite, and perhaps paradoxical,
directions (i.e., not always or only toward diminishment). Philosophers discuss whether a truly
thin notion of “core self” or minimal self-presence should be considered a sine-qua-non either of
Here we take no position on these vexed questions. Our focus is on comparative and empirical
issues concerning variations of felt self-presence that might be discernable across diverse
psychiatric conditions or between distinct kinds of human experience. For us, the key opposition
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would not be between a (presumably normal and constant) presence of self-presence versus its
(supposed) absence or diminishment in schizophrenia, but rather: between more normal forms of
pre-reflective immersion and absorption, however these be understood (that is: whether as
involving minimal self or not), versus hyperreflexive experiences involving altered self-
presence.
and waning over time) has long been recognized, and currently fuels skepticism about the
opposite and even paradoxical aspects could contribute to such doubts. “Schizophrenia” does,
however, have a long history, and there are reasons to consider it a valid and necessary
category.24 Like nearly all psychiatric diagnoses, schizophrenia is unlikely to be a true “disease
entity,” with a unifying or singular cause and course; rather it is a syndrome comprising a diverse
set of co-occurring features. But this does not mean we must forego all further explanation,
limiting ourselves to listing co-occurring symptoms and signs. We agree with Karl Jaspers’ view
“Cogito”).25
The IDM is one attempt to clarify and account for the unity of this condition; it describes
a number of aspects that are intimately inter-related in various ways. We will now suggest that a
component of the IDM—hyperreflexivity—may be the best candidate for bringing the disparate
features of the syndrome together by showing their mutual implications and understandable
générateur: namely, a shared or unifying theme that permeates all the major symptoms as well as
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an originating process, an orientation or existential mode that contributes to development of
and grip—and with the paradox of their co-occurrence—offers a way of understanding what can
otherwise seem the strange or even inconceivable experiences that can occur. We shall argue that
such an approach is congruent as well with the agentic ambiguities of schizophrenia, 27 that is,
with its distinctive combination of quasi-intentional with passively endured factors (of “act and
affliction”28), and with the temporal variability of symptoms29-30 that this combination may help
to explain. As we shall see, such an approach locates the essence of schizophrenia not as
diminishment or loss but as a heightening of the paradoxical heart of human subjectivity itself:
might otherwise have remained in the background of experience. It obviously implies a kind of
inward-turning but also an extrusion, an alienation of that which is taken as the object of
ambiguous. Here it will refer to a condition in which something is directed or turned back upon
itself, and this should be understood in an inclusive sense. The “reflexivity” in “hyperreflexivity”
(these might be termed hyper-reflective hyperreflexivity), but also to a more passive undergoing
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focus (termed “operative hyperreflexivity”)—as when a patient finds herself noticing, say,
kinaesthetic or proprioceptive sensations in her elbow or eye sockets, or somehow “hearing” the
inner speech that would normally serve as the unnoticed medium of her thinking. The operative-
dichotomy.
Historical antecedents: The relevance of such inwardness and associated alienation have
long been recognized in classic psychiatric accounts of schizophrenia that are attuned to the
subjective dimension. The importance of inwardness is already evident in Eugen Bleuler’s notion
of “autism,”32 which refers to the turning-away from the external and social world that he viewed
as a defining symptom of schizophrenia.33 Both Eugene Minkowski’s “loss of vital contact” 26 and
Wolfgang Blankenburg’s “loss of natural self-evidence” 34 (of the sense of obviousness or the
taken-for-granted) reflect this turning inward. Together they capture the accompanying
sense of things being uncertain and arbitrary) that prevail, often giving rise to metaphysical
simultaneous and complementary, in the experience of both world and self. 36 These are first, the
from the Greek for “to become manifest”), and second, Anastrophe: a “stepping-back” from
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The Japanese psychiatrists Kimura Bin37 and Nagai Mari38 describe a kind of constant and
involuntary “self-witnessing” as the key feature. Their subtle but difficult account of self-
witnessing brings out the inherently paradoxical aspect of schizophrenic selfhood, involving
even, the achieving of heightened self-presence only at the cost of a certain alienation from one’s
immediate subjectivity. Kimura and Nagai describe the kind of self-consciousness found in
schizophrenia as unusual insofar as the consciousness that is somehow watched by itself does not
thereby lose its quality as consciousness or as a gazing upon the world (i.e., its awareness of a
certain “for-me-ness” of its own experience). Such paradoxical forms can hardly be captured by
a simple notion of diminished self-presence or minimal self, since they incorporate the increased
knower.
The term “hyperreflexivity” was introduced through discussion of the myriad parallels
between classically schizophrenic experience and expression and that typical of the modernist
and postmodernist art, literature, and thought of the 20 th century—that is, of artists (and
movements) who turned the normally tacit foundations of both art and experience into the main
subject of their work.28 Such artists and movements engendered all manner of conceptual and
experiential contradictions—and did so by taking subjectivity or mental life as both the prime
object of attention and the “sovereign subject” or constituting center of all that exists (as what
Foucault termed the “empirico-transcendental doublet” 39). Such contradictions are indeed
“paradoxes of the reflexive.”28 The parallels between madness and modernism can serve to
illuminate schizophrenic phenomena that are too readily dismissed as demented, regressed, or
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simply incomprehensible, but that, in fact, demonstrate the peculiar, and often paradoxical,
Let us return to the experiential abnormalities described in our first article, but considering them
—whose association with hyperreflexivity might seem particularly obvious. Then we consider
The hyperreflexive aspect of exaggerated self-presence is, perhaps, almost too obvious to
require elaboration. It would seem that exaggerated self-presence just is a heightened awareness
of one’s own being aware. It is, after all, a bringing-to-the-fore of something that would normally
be taken for granted and thereby recede to the background, or, perhaps, would not be registered
in consciousness at all—i.e., the sheer fact of existing as, or of having, a field of conscious
schizophrenia42-43—may reflect how the world can seem derealized in the presence of this
hyperreflexive self-awareness of awareness as such: “I see things devoid of substance … what I
see is only a play, a Punch and Judy show; it is clumsy, vulgar, unpleasant and, above all, false; it
doesn’t really exist”44. “There is no reason for believing in the existence of an unobservable like
an external world, and therefore my mind, cluttered with surprisingly uncooperative images, is
my only reality”45.
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Here the “for-me-ness” seems to be exacerbated and extended, not diminished: A person
who experiences even real-world objects, persons, or events as lacking a certain independence
and solid reality may be hyperaware of her own consciousness as the (constituting) medium of
experience, and therefore of objects in the external world as having what might be termed a
“coefficient of subjectivity.”46
Exaggerated for-me-ness seems relevant as well for exaggerated grip, whether in what we
have described as its mystical or its ontologically paranoid form. In the mystical case, a
heightened sense of coherence and salience evokes feelings of higher unity or mystical
wholeness, such that patients feel directly aligned with ultimate aspects of reality that may have
of a hyperreflexive awareness that renders all things quasi-subjectivized and thereby equivalent.
In the paranoid case, the sense of oneself as the conscious center of things grounds the
feeling that other conscious centers must be attending to oneself as the ultimate centerpoint and
therefore as the target of greatest interest. This hyperreflexive interpretation of paranoia may also
account for its often ‘ontological’ character in schizophrenia (cf. article 1), i.e., the fact that such
paranoia is often not limited to particular persons or entities (as would be the case in, e.g.,
delusional disorders),49 but tends to extend to the whole of reality, for example, as involving
impersonal gazes or cameras that possess a ubiquitous or allover mode of presence, both internal
and external. One patient is “examined throughout my life—secret cameras and microphones
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whirring in my head”50. “There was something there,” said another, “beneath me, behind me,
The prominence of hyperreflexivity (though not the term) is essential to the French
psychiatrist Henri Grivois’51 account of schizophrenia as being grounded, in its origin and
essence, in the patient’s experience of his own centrality in the universe (“centration”) and of
discussed in our previous article. And these, in turn, could obviously account for what, since
Bleuler, have been recognized as the most common delusions in schizophrenia: those involving a
appear to be grounded in a fundamental alteration in the way in which self and reality in general
has just been described, yet they too can be bound up with hyperreflexivity.
One route is already elaborated in the IDM1-2 and earlier in Sass’s Madness and
normally be lived through in an implicit manner—and would thereby serve as the medium of a
reified. (This may affect, e.g., the inner speech supportive of thinking or the kinesthetic and
proprioceptive sensations of the body.) In the current IDM this is described as undermining a
supposedly normal and constant sense of implicit self-presence (“minimal self”). It can also be
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stimuli into what might otherwise have been a transparent, world-directed, or meaning-directed
flow.22
In accord with either interpretation, the patient may well be expected to complain of a
certain “loss of self”—referring thereby either to a loss of implicit self-presence that would
“You’re on automatic pilot and you’re an observer,” reported one patient. “You’re doing all kinds
of stuff but it’s like you’re not really present, as if you’re observing everything from your own
fashion and interrupt more spontaneous or habitual modes of awareness and action. Others may
involve more reflective forms of hyperreflexivity, in which self-directed attention would have a
more secondary as well as a partially volitional quality. The patient may, for example, attend in a
somewhat intentional or goal-directed fashion to normally implicit sensations of which she finds
herself becoming aware (or to other kinds of abnormal perceptual experiences felt as unusual), iii
perhaps in order to monitor or somehow control their disruptive effect—even though (as noted
above) this very attentiveness is liable to exacerbate the very alienation or abnormality she is
attempting to control.
studies regarding the development of schizophrenic “first-rank symptoms” from the initial and
underlying subjective phenomena known as “basic symptoms”. 52 The symptom sequence begins
perceiving, thinking, or the body, often involving sensations that would normally have remained
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in the experiential background (a kind of operative hyperreflexivity). Patients who eventually
developed symptoms involving loss of bodily possession, for instance, had earlier experiences of
sensations or subtle feelings of enlargement or diminishment of body parts. 53 Over time such
processes of adaptation and coping,” including “checking efforts” and attempts to give meaning
or exert control over these emerging sensations (reflective hyperreflexivity)—all this typically
leading eventually into classic symptoms of truly not owning one’s own thoughts, or perhaps of
Here, it seems, the awareness and the experiential alterations should not be viewed as two
separable things (as if the first were a mere noticing of the second). The very fact of being so
aware (so focally aware) may actually alter the experiences in question through a kind of
reification, a process whereby subtle background forms of awareness are made to take on the
more explicit qualities of an object of focal attention—thereby manifesting what R.D. Laing
aptly termed “phantom concreteness.”46 Antonin Artaud, who suffered from schizophrenia,
experienced his own facial sensations, normally lived tacitly from within, as taking the form of a
“vitreous” masklike membrane that seemed to rise off from his own face.54
It should be noted, as well, that the very act of searching for oneself can be understood as
a futile and perhaps counterproductive attempt—for as various philosophers (Hume, early Sartre,
and many Buddhist thinkers) have argued, there may be no self if the latter is defined as some
necessary and constant object, or even as a reliable sense of presence. In such cases, in fact, it
may be the very looking for something that, by its very nature, cannot actually be found, that
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brings on a sense or an awareness of ungrounding that would not be present in normal, ongoing
experience.
The seemingly contradictory dualities of grip are no less striking and no less explicable in
light of hyperreflexivity.
object of all awarenesses. We have considered how this may give rise to delusions of reference,
the ontological paranoia of a “watcher-machine,” or the sense of nothing being random since
everything is somehow organized in relation to oneself (usually the patient cannot say just how).
Antithetical developments can also occur, however, given a second factor. This is the fact that
withdrawal from direct and vital engagement with the external object-world—which can also be
that lend pattern to one’s field of awareness, thereby undermining the normal sources of
These two possibilities correspond to the classic distinction made between two main
types. Research shows that these classic subtypes do not in fact separate out very clearly, with
many patients showing both types of symptoms at different stages of their illness or even
manifesting both disorganization and paranoia at the same time. 56 (Recognition of this
overlapping has led to elimination of the subtype designation in the latest diagnostic system.)
The common thread of hyperreflexivity can help explain how these two aspects—seemingly so
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opposed—might stem from a shared underlying core, from different potentialities inherent in
hyperreflexive withdrawal.
It appears, then, that hyperreflexivity can capture the co-existence of symptom and
counter-symptom that (as Vygotsky noted, see article 1) seems endemic to schizophrenic
conditions. Diminished and heightened self-presence; loosened and tightened grip; grandiosity
and paranoia: both sides of each of these dualities can be understood as manifestations of the
inwardness and alienation implicit in this introversive form of existence. These two sides of a
coin are sometimes combined in representative schizophrenic symptoms that capture their
Natalija posits herself as both the godlike center of all that appears and as a mere machine
A closely related duality is apparent when Schreber recounts how his paranoid sense of
being watched and controlled by the ‘nerves’ and ‘rays’ of God was intimately related to his own
quasi-divine importance as the ultimate center of reality. 58-59 It is perhaps not surprising (indeed,
perhaps is inevitable) that the one who feels himself to center or anchor the world (“I have the
should also be the person toward whom all meanings and messages are directed, the very one
whom everything concerns—as if everything orients around oneself, rather like iron filings
pointing toward a magnet. In this sense centration and concernement are complementary or
mutually interdependent—two sides of a coin. There may, however, be times when one or the
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other takes the fore, leading to oscillations between a more grandiose and a more paranoid
orientation.
Here a useful analogy is that of a sniper who, peering through his gunsight, naturally
senses his own centrality as the point-of-origin of what seems the all-powerful cone of awareness
that splays out before his own scrutinizing eye, yet who must realize as well (all the while, or
perhaps, just before pulling the trigger) that all enemy glances might seek out and potentially
converge on him, thereby transforming his own sovereign viewpoint into the target of a kind of
ontological “search-and-destroy” mission. This might serve as a real-world analogy for the co-
paranoia that are two aspects (antithetical, yet also complementary) of a hyperreflexive
Variability: We have noted hyperreflexivity’s compatibility with, and indeed, its ability to
antithetical symptoms that might seem mutually exclusive. Also significant is this construct’s
compatibility with the variability of symptoms, referring now to how symptoms may wax or
wane over time, sometimes imposing themselves forcefully but at other times fading away. 29-30
By contrast, “diminished minimal self” suggests a persistent condition (and has indeed
sometimes been understood as such) 60 that is supposedly invariant, though somewhat changeable
in its expression; it refers to an underlying state of being rather than to any process that may have
brought this state about. The concept has rightly been criticized for its seeming inability to
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account for why sense of self appears “relatively intact prior to illness onset” but then is lost, and
also for how this sense could possibly be regained or reconstructed in processes of recovery.61
alienated attitude that unsettles the taken-for-granted and disrupts concentration and habitual
forms of spontaneous flow. Like the self-centrality it grounds, the tendency toward
might develop its own inertia and persistence, becoming almost habitual, but also that it is likely
to wax and wane in accord with internal moods or other states and in reaction to external events
or interpersonal experiences that may be experienced as threatening or soothing 62—and that these
shifts may occur spontaneously, as a mindset that can overtake a person yet without being
studying whether temporal increases in hyperreflexive patterns are predictive for the
periods of remission and recovery—thereby testing a phenomenological model of the onset and
development of schizophrenia spectrum disorders that can complement and enrich current
prediction approaches.64
Persons with schizophrenia describe such variability and, with it, the possibility of having
some modicum of control.27 Patients do sometimes manage to quiet their voices, often by
engaging in familiar forms of practical activity, like shoveling snow or washing the dishes. 65-66
They may also bring on unusual experiences through intense hyperreflexive concentration that
can bring about a sense of self-alienation but also a sense of universal centrality. 67 The latter
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propensity—for intense concentration—may typically be described, in psychiatry, as a defect,
deficiency, or weakness, but could be thought of equally well as a capacity, perhaps even a kind
Earlier we described the apparent variability of self-presence in more standard and clearly
self-aware activities or situations). What is it, we may ask, that differentiates these from the
a matter of type or of degree? Or is it related to the specific nature of the hyperreflexivity that
predominates in schizophrenia68?
also be quantitative differences in the intensity of the processes or in how often or long they
persist, or in the degree to which the person is able to flexibly modulate forms of tacit immersion
and states of reflexive consciousness. But beyond this it may be necessary to describe as well,
certain limitations on how seriously such changes are taken, given what could be described as the
For most “normal” individuals, indeed for most people who are not in the schizophrenia
spectrum or currently psychotic, something like what phenomenologist Edmund Husserl termed
set of constraints, regarding reality-in-general, that persist as the underlying and unchangeable
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framework of waking life. This includes assumptions, normally too obvious to be spoken or
thought, that preclude either of the polarized extremes to which hyperreflexivity can lead: such
“urdoxa” (foundational presuppositions) as the fact that there is an external world, that other
subjectivities distinct from but akin to us exist, and that one does oneself exist (though without
any insistence on its being in every moment recognized from within). One may ask whether it is
the fragility of a person’s grounding in this attitude and its urdoxa that makes schizophrenic
hyperreflexivity possible or distinctive (for this suggestion, see 70-71): perhaps only then can a
person engage in such inward, unconventional, and alienating forms of self-consciousness which
can lead to extreme experiences either of loss of self or of its apotheosis. Or to the contrary, is it
often has a “transcendental” flavor, given its tendency to “bracket” or set aside the “natural
is, to take “subjectivity” rather than objective reality as primary. (By contrast, the natural attitude
reality72)v
seem in any case to be intimately related. 28,47,74-75 Together they seem to capture, if not the
“essence” (which may not exist) then at least the distinctive signature of the diverse yet real
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This revision of the IDM (see Figure 1: panel A+B) has implications for both research
and treatment. Consider first the issue of neural correlates and neurobiological modelling.
The neural plane: The minimal-self model would seem to motivate, most naturally, a
search for a shared neural factor that (supposedly) would underlie the various forms of
diminished minimal self experience—almost a kind of holy grail that would index and perhaps
account for this supposedly key abnormality that is assumed to lie at the core of the overtly
is more diverse and modest in its ambitions—and more in line with current empirical research on
neurobiological correlates.
primarily or exclusively with diminished self (nor with the hypotheses of diminished meta-
cognitive awareness76), but with the forms of self-conscious introversion captured by the
hyperreflexivity notion. And these, in turn, might be expected to be heterogeneous, given the
out of kinesthetic sensations that would normally have been unnoticed or suppressed (“operative
personal centrality (perhaps correlated with hyperactivation of the DMN: Default Mode
Network79 ) or else confusion regarding what is experienced as being “inner” versus as “outer”
(perhaps correlated with unusual positive correlation of DMN with the CEN: Central Executive
Network80). Rather than a unipolar abnormality, there seems a general instability—reflected, e.g.,
22
in predictive-processing studies showing weaker but also stronger “priors” in psychosis 81, or in
We suspect that, rather than having any single neurobiological correlate, schizophrenia
needs to be appreciated in its diversity—the heterogeneity of its symptoms going along with a
heterogeneity of neural correlates. The unity underlying (or coexisting with) this diversity may
need to be identified on the psychological and indeed the phenomenological plane—as involving
what might be termed a final common pathway, a “real” or “robust pattern” 83, a kind of “attractor
basin”84 (or “strange-attractor” basin85—allowing for heterogeneity and fluctuations) whereby the
different aspects of hyperreflexivity (in both operative and reflective forms) occur in a variety of
both causally interacting and mutually implicatory ways. 4 Such a basin could, of course, have a
Psychological treatment: Implications for treatment were addressed at the end of the
previous article. There we discussed the nature of heightened self-presence and tightened grip, an
appreciation of which can help overcome the tendency either to find such experiences
appreciate the central importance of centration itself, and thus of key symptoms such as
The most significant implications may pertain less to any specific therapeutic technique
and more to an atmospheric shift.86 This would involve overcoming a kind of epistemic injustice
that is widespread and difficult to dislodge: that of condescending to the patient’s perspective by
viewing it not only as inaccurate but as somehow less developed or mature than that of the non-
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failures of logic or regression to primitive modes, “hyperreflexivity” allows them to be, at least
reflexive.”28,39-40.
Final comment
understanding schizophrenia is, of course, only a hypothesis, and will need, over time, to prove
its superiority to alternative hypotheses. Here we have argued that hyperreflexivity accords with
the diversity of symptoms in schizophrenia; can account for its distinctive paradoxes; and offers
a way of understanding its agentic ambiguities and of conceiving its variability over time. We
have suggested various empirical and practical implications. We note as well that whereas
diminished “minimal self” suggests a loss of the kind of self-consciousness that seems almost
definitive of human nature, “hyperreflexivity” views schizophrenia squarely within the human
Acknowledgements
The authors want to thank Barnaby Nelson, Mario Alvarez, Wouter Kusters, Stijn Vanheule, Matt
Millar, and several anonymous reviewers for their helpful feedback on earlier versions of this
article.
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ENDNOTES:
30
i
Exaggerated self-reflection is explicit in Blankenburg’s account of “loss of natural self-
evidence,” though Blankenburg presents such self-consciousness largely as a product (a defensive
reaction) rather than source for this undermining of the obvious or taken-for-granted.34
ii
Such delusions should be understood not merely in terms of their meaningful symbolic content
and in relation to the patient’s biography (as Bleuler and Freud often recommended) but in relation to
the ontological transformations that occur (which is more in accord with Jaspers’ views).
iii
Hyperreflexivity might sometimes be secondary to perceptual anomalies that are not themselves
necessarily hyperreflexive in nature. We would nevertheless argue that, when distinctively
schizophrenic features develop, these are likely to be bound up with hyperreflexivity. See text re
“attractor basin” notion.
iv
Re the typical alterations of attitude and orientation in schizophrenia-spectrum, see EASE
section V35 and EAWE section VI69 (which are highly overlapping).
v
We speak of transcendental hyperreflexivity by analogy with Husserl’s “transcendental” versus
“empirical” forms of reflection.73