Is minimal self preserved in schizophrenia? A subcomponents view

Consciousness and Cognition Consciousness and Cognition 16 (2007) 715–721 www.elsevier.com/locate/concog

Commentary

Is minimal self preserved in schizophrenia? A subcomponents view q Aaron L. Mishara

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Department of Psychiatry, Clinical Neuroscience Research Unit, Yale University School of Medicine, CMHC 333-A, 34 Park Street, New Haven, CT 06519, USA

The self is one of the most important, but also, one of the most elusive concepts in the study of neuropsychiatric disorders. Cermolacce, Naudin and Parnas (this volume) have provided a thoughtful analysis of self in schizophrenia by applying phenomenological concepts to two case histories. Following the conceptual model developed by one of its authors (Sass & Parnas, 2003), they interpret the first case (Maria) as exhibiting a reduced sense of being a self (i.e., what they call ‘‘ipseity’’)1 and the second (Thomas) as exhibiting ‘‘an excessive tendency to monitor, and thereby objectify his own experiences and actions, . . . or hyper-reflectivity.’’ In their conceptual model, Sass and Parnas (2003) observe that these two tendencies are related: ‘‘exaggerated self-consciousness [is] associated with diminished self-affection and disturbed ipseity.’’ Critical for this commentary, however, is Cermolacce et al.’s brief mention of still another tradition in phenomenological psychiatry.2 This tradition leads to fundamentally different conclusions about the disruption of self-experience in schizophrenia. I briefly present the alternative model and how it leads to different conclusions. Cermolacce et al. (this volume) propose that disrupted self-experience in schizophrenia is the reflection of a reduced (but preserved) minimal self (i.e., a pre-reflective bodily self-awareness). In this commentary, I propose that it involves dysfunctional pre-attentive binding between subcomponents of self (e.g., ‘‘I,’’ ‘‘me’’ and ‘‘mine,’’ so far as these are captured in language) prior to the emergence of self as a unitary experience in awareness. Due to a weakening in binding, these components appear as separate, disjointed moments in the conscious experience of neuropsychiatric patients, including patients with schizophrenia, and anomalous conscious states (e.g., out of body experiences (Blanke, Ortigue, Landis, & Seeck, 2002)), dissociative states in trauma-related mental disorders,3 delusional misidentification syndromes, autoscopy (Mishara, 2005), acute psychosis, dreaming and the

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Commentary on Cermolacce, M., Naudin, J., & Parnas, J. (2007). The ‘‘minimal self’’ in psychopathology: Re-examining the selfdisorders in the schizophrenia spectrum. Consciousness and Cognition, 16, 703–714. * Fax: +1 203 974 7662. E-mail address: [email protected] 1 From the Latin for self, or itself, ipse. 2 In their footnote # 10, Cermolacce et al. (this volume) write: ‘‘Schwartz and Wiggins (1992) are of the opinion that the basic disorder in schizophrenia is at the level of ‘‘passive syntheses’’ (a Husserlian term denoting automatic, associative-self-organizing, pre-egoic processes, preceding the articulation of a full fledged ego relationship).’’ This approach, which examines the deformation of Gestalt perception and the resulting disruption of self-experience (in terms of Husserl’s concept of ‘‘passive synthesis’’), arises from an entirely different tradition in phenomenological psychopathology than the ‘‘hyperreflexive’’ approach emphasized by Cermolacce et al. 3 For example, rape victims sometimes report dissociative experiences, ‘‘such as the sense of watching the rape from outside their bodies’’ (Foa & Riggs, 1993, p. 281). 1053-8100/$ - see front matter ! 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.concog.2007.07.009

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‘‘psychotomimetic effects’’ of hallucinogens and dissociative anesthetics (Vollenweider & Geyer, 2001).4 Binswanger (1957, 1965), who is a major proponent of the alternative to ‘‘hyper-reflexivity,’’ proposes that the minimal self (so far as it is preserved at all) in schizophrenia is failed self-transcendence as being-in-the-world. This failed self-transcendence and related symptoms (e.g., perceptual anomalies, delusions, thought insertion, auditory hallucinations, avolition) are due to impaired sensori motor integration and automatic processing (mediating shifting ego- and allocentric frames of reference) before ever reaching consciousness.5 I will relate the components view of self (and their putative neural substrates) to an existential (phenomenological) view of self as an ongoing

4 This approach was articulated by a generation of predominantly German-speaking psychiatrists (e.g., Binswanger, Blankenburg, Conrad, Matussek; see recent review, Uhlhaas & Mishara, 2007). It is different in origin and emphasis than what contemporary proponents of a phenomenological psychopathology call ‘‘hyper-reflexivity.’’ Husserl’s concept of ‘‘passive synthesis,’’ i.e., the automatic processes underlying the organization of our experience in time is a critical concept for Binswanger, Blankenburg, and later Schwartz and Wiggins who view delusions in schizophrenia as arising from the breakdown of Gestalt-perception and resulting anomalous perceptual experiences. 5 The existential-phenomenological approach differs from the hyperreflexivity/ipseity model on the following points: (1) The disruption of experience in schizophrenia is on the level of pre-intentional passive synthesis, not higher order ‘‘intentionality.’’ By remaining on the level of intentionality, the hyperreflexivity/ipseity model does not reach ‘‘deeply’’ enough (see Mishara, 1990a) into the automatic processes shaping our experience: The hyperreflexivity/ipseity model views the core deficit in schizophrenia to be on the level of ‘‘intentionality,’’ i.e., the property of aboutness or relatedness which enables consciousness to experience fully constituted (constructed) ‘‘objects,’’ explicit parts of these objects or self (as object). In this view, there is in schizophrenia a disruption of a ‘‘tacitly’’ functioning ‘‘operative intentionality’’ (non-conscious intentionality) that forms the ‘‘background’’ of consciousness. Hyperreflexivity (or exaggerated self-reflection) may itself become automatic in schizophrenia leading to the ‘‘pop out’’ of irrelevant background stimuli and disruptive bottom up processes. In contrast, the existential-phenomenological approach holds that the disruption of perceptual Gestalt, agency and sensorimotor integration in schizophrenia rests on ‘‘pre-intentional’’ passive, automatic processes outside awareness that are prior to, and the precondition of ‘intentionality’ in both its explicit and implicit modes. Relying on Husserl (1966) and Von Weizsaecker (1968), existential phenomenological psychiatrists (e.g., Binswanger, Blankenburg, Schwartz and Wiggins) propose that the perceptual anomalies and resulting symptoms in early schizophrenia, e.g., the formation of delusions, disrupted self-experience and the loss of common sense (see Uhlhaas & Mishara, 2007), rest on something more fundamental in the shaping of experience than dysfunctional conscious intentionality or tacit ‘‘operative intentionality.’’ (2) Naı¨ve absorption in experience involves a loss of self-awareness: In the hyperreflexivity/ipseity model, ‘‘we are self-aware through our practical absorption in the world of objects’’ (Sass & Parnas, 2003, p. 430). In the existential-phenomenological approach, absorption and self-awareness—although related to one another—are mutually exclusive: The more absorbed or practically engaged I am in my experience, the less self-aware (or conversely, the more selfaware, the less engaged) in a foreground/background relationship (Von Weizsaecker, 1968). In naı¨ve experiencing, there is a ‘‘loss of self’’ (Selbstverlorenheit): ‘‘the moment I begin to reflect, the naively perceiving, self-forgetting I is already past. (Husserl, 1959, p. 88, my translation). I am only able to reflect on my original, naı¨vely absorbed self-forgetting ‘‘I’’ because the ‘‘I’’ itself has split (Ichspaltung) into a reflecting ‘‘I’’ and the object of its reflection, the immediate previous ‘‘I’’ engrossed in its experiencing (Husserl, 1959), now a ‘‘me’’ or object of the ‘‘backwards reaching’’ reflection. (3) Explicit self-reference is reflective and after the fact: For hyperreflexivity, ‘prereflective self-awareness... entails a built-in self-reference’ (Sass & Parnas, 2003, p. 430). The existential-phenomenological approach emphasizes that any conscious reference to self is not self but post-facto, an imagerepresentation of self, that is, having a self, a ‘me’, rather than (prospectively) being a self, an ‘I’ open to its own future (Theses 2 and 3). Interestingly, to the extent that controlled, conscious processing is relaxed, self-reference may occur spontaneously and implicitly in images or metaphoric language (Thesis 5): Silberer (1909) woke himself from his own hypnagogic imagery before falling asleep and made detailed observations. He observed that to the extent that he was no longer self-conscious (i.e., awake), the self spontaneously represents its own activity ‘‘symbolically’’ in images: The image-formingprocess becomes symbolic (i.e., self-referring) the moment it falls below a certain threshold of controlled processing or awareness. That is, there is spontaneous self-reference but it functions precisely to the degree that it remains nonconscious, i.e., not directly formulated in awareness, without reflexivity or hyperreflexivity. (4) The hyperreflexivity/ipseity model claims to ‘‘explain’’ schizophrenia and thereby ‘‘constrain’’ clinical neuroscience in a unidirectional relationship; in contrast, the existential phenomenological approach holds that phenomenology’s role is not to constrain neuroscience but to provide hypotheses for further experimental study (see Mishara (2007) for discussion). (5) In contrast to the experimental evidence for disrupted preattentive perceptual and efferent binding (and the related concept of passive-synthesis) in schizophrenia (Uhlhaas & Mishara, 2007), there is little or no experimental support, direct or indirect, for the hyperreflexivity/ipseity model: Most research suggests that patients with schizophrenia exhibit decreases in attention and self-monitoring rather than increases or exaggerations in these cognitive functions. These findings appear to lead to a conclusion opposite to hyperreflexivity. During self- and performance-monitoring tasks, patients with schizophrenia often, but not always, exhibit reduced anterior cingulate activation, which is thought to subserve the self-monitoring function. Finally, there is increasing evidence that this sort of monitoring may not require awareness (Klein et al., 2007; Mishara, Greig, Nicholls, & Bell, in revision; Nieuwenhuis, Ridderinkhof, Blom, Band, & Kok, 2001; Schooler, 2002). Therefore, abnormality of self-monitoring in schizophrenia may not involve conscious processing whether hyperreflexive (Sass & Parnas, 2003) or (predominantly) hyporeflexive (Frith, 2004). Nevertheless, Parnas, Møller, Kircher et al. (2005) have developed a clinical rating scale of schizophrenia based on a semistructured symptom-checklist to study the hyperreflexivity/ipseity model empirically. To date, however, it is not clear that the concepts hyperreflexivity, ipseity and prereflective self-awareness have been adequately operationalized to rule out alternative interpretations or whether the concepts are sufficiently precise or possess sufficient detail to be operationalized. The instrument is in its early phases of study and its psychometric and discriminative properties remain unknown. Moreover, attentional capture may be more parsimonious in its explanation of overattention to details or the inability to transcend the current experiencing of one’s current perspective (Thesis 4) in schizophrenia than the hyperreflexivity/ipseity model (Uhlhaas & Mishara, 2007). In its current form, the hyperreflexivity/ipseity model is not able to constrain clinical neuroscience by ruling out alternative, more mechanistically detailed hypotheses (Mishara, 2007). Its claims are highly controversial within phenomenology and there is no compelling reason why these particular constructs should be favored over others (e.g., passive-synthesis (Mishara, 1990a)). (6) The two approaches, hyperreflexive and disruption to preintentional perceptual-automatic processing (existential phenomenological approach), have been labeled Apollonian and Dionysian approaches, respectively. See Gallagher (2007) and Uhlhaas and Mishara (2007) for references to this debate.

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process of self-displacement or self-transcending. I present several theses summarizing this position, which I elaborate in the discussion that follows: (1) Self (subjectivity) is the stream of consciousness as a (transcendent) totality. (2) Self is not a mental representation but an ongoing process of integration d!e nov! o. (3) The components of self can be mapped heuristically onto neural pathways proposed by Paillard and others to involve a body schema (body for self) and body image (body for others). (4) In acute psychosis of schizophrenia, the self is captivated in the present moment (a ‘‘temporal shrinking’’ of past and future (Binswanger)) and the ability to transcend current experience is compromised. (5) When controlled processing relaxes, metaphoric images of self spontaneously arise (e.g., hypnagogic images, spontaneous metaphors in narratives).6These reflect the self in its dual movement in time as advancing towards the future and letting go of the past. (6) Symptoms of schizophrenia such as delusions are a way of preserving the self (minimally) when the process of self-transcendence has been impaired. In delusions, metaphors of self are interpreted literally to reflect those aspects of the self which are still preserved. Thesis 1. proposes that the self is the stream of consciousness as a (transcendent) totality. This involves both conscious and non-conscious, automatic processes. Husserl labels the automatic processes, ‘‘passive syntheses,’’ which underlie each now point in an ongoing process of a self-displacing present. In a not oft-cited passage, Husserl writes that the ‘‘self’’ as the ‘‘streaming consciousness in itself’’ is ‘‘transcendent’’ to conscious experience. It ‘‘is only incompletely and approximately given in any particular recollection of a past now’’ as it ‘‘streams off as retention’’ (i.e., the passing of a fresh impression into the immediate past and thus, briefly ‘retained’ as still present in the current now) or subsequently, when recalled in memory (see Mishara, 1990a).7 We experience our consciousness as an obligatory displacing itself with each new now. Nevertheless, we do not have reflective access to this process which is fundamentally self. As Husserl writes, ‘‘the streaming is always ahead (im voraus). . .’’ Because reflection occurs within the conscious experience of time, it is always subsequent to the original self-displacing movement of consciousness and itself passes off in time as retention. Without the stream itself being transcendent to consciousness, there could no autobiographical past which attaches to this stream. For Husserl, the in itself of (transcendent) streaming-consciousness is passively (and largely nonconsciously) constituted, but without it, there would be no self, and no past. The human self is not its representations but a process (Thesis 2). Any reference to (or representation of) self as entity is pars pro toto (taking a part for the whole) and is after the fact. In existentialist terms, the human self is ‘‘condemned’’ to self-transcendence, i.e., condemned to prospectively transcend each of its current representations of self. Being (rather than having) a self is the ongoing vulnerability of being oriented towards the future, the not-yet-known. In Husserl’s terms, the self is affectively tied to its own field of experience as a field of possibilities (Mishara, 1990a). The sense-fields are themselves structured in terms of a kinesthetic system (Husserl) in which ‘‘I move myself’’ is at the core of each momentary organization (i.e., how body-schema structures perceptual experience in an anticipatory but non-conscious manner, Thesis 3). Sartre (1966) had identified consciousness with boundless freedom, a nothingness—a ‘‘knife-blade’’—which is condemned to continually sever itself from what it just was.8 Consciousness has to cede each image or representation of itself as already surpassed by the next now-perspective which replaces it. The persistence of self-identity in time is paradoxical: the self is (being a self) only to the extent that it is not what it just was (having a self). The problem of self-identity (as it is usually posed) is petitio principii:‘‘Because I am self, I must be the same self I just was.’’ The existentialist 6

See Silberer (1909), Mishara, 1995, and discussion of self-reference below. ‘‘A now-point cannot become conscious without something past or which has just been attaching to it. Therefore, ‘memory’ belongs fundamentally to the unity of each perceptual process. We call ‘retention’ that which attaches with complete immediacy to the consciousness of now.’’ (Husserl, 1966, p. 315, my translation). Each original now-impression ‘‘constantly passes over into a stretch of fresh retention’’ which for a time can be viewed as temporally extended. This occurs in an automatic, passive process of continual modification in which each passing now ‘‘becomes ever more past’’ before disappearing into a horizon of the past (Vernebelungshorizont, i.e., a horizon of clouding over) (Mishara, 1990a). 8 Self as the process of self-transcendence is reflected in Sartre’s famous phrase, ‘‘existence precedes essence’’ where essence (citing Hegel) is ‘‘what is already past’’: ‘‘Wesen ist, was gewesen ist.’’ 7

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view is the converse: ‘‘I am a self precisely because I am not what I just was.’’ Any representation of self is already past (having a self), with its own closure (i.e., encoded in allocentric coordinates, embedded in scene-based relational cues between objects; it is as if the remembered body itself—as body image (Thesis 3)—were an object in relation to which we assume a quasi-external viewpoint). This retrospective unity (body-image) cannot replace my current openness to a future, an incomplete openness with each new now moment. Many efforts to study self confuse the representation of self with being a self (Legrand, 2003). Simply put, most experimental studies of self as self-representation access the social-self (the ‘‘me’’ of body-image) but not the I (open to its own future).9 With regard to thesis 3, the distinction body-image/body-schema is that between ‘‘a conscious awareness of one’s own body’’ and ‘‘a nonconscious performance of the body’’: ‘‘Proprioceptive information is obviously necessary for updating the postural body frame (or schema), whereas exteroceptive multimodal information, mainly visual, underpins the central representation and percept of the body image. . .’’ (Paillard, 1999, pp. 197– 198).10 The body-schema provides a ‘‘path structure’’, superimposed on a collection of separate points, in a vectorial map which defines in egocentric terms how awareness is able to shift from a current ‘‘here’’ to an anticipated but still not consciously known ‘‘there.’’ Paillard (1999, 2005) acknowledges the overlap of his model with Milner and Goodale’s (1995) proposal for a ‘‘vision-for-perception’’ ventral system which is more recently evolved (mediating awareness) than the more ancient ‘‘vision-for-action’’ dorsal system. For Milner and Goodale, the dorsal stream projecting from primary visual cortex to the superior parietal lobes is a key component in an action pathway of visual processing. Ungerleider and Mishkin’s (1982) classic what/where dichotomy of visual processing—serving as the basis for Milner and Goodale’s proposal—was prefigured by Trevarthen’s (1968) distinction of a ‘‘focal vision’’ for the ‘‘whatness’’ of an object from an ‘‘ambient vision’’, which locates ‘‘where’’ a relevant stimulus might be in the periphery relative to current focal vision (Paillard, 1991a, 1991b, 1999, 2005).11 Information may be relayed to the dorsal or ventral pathways based on its peripheral or central location in the visual field. Information from the peripheral visual field has faster access to the implicit body-centered computations of dorsal processing streams than the slower ventral pathways subserving conscious focal awareness.12 A third interoceptive pathway mediates the inexorable ‘‘mineness’’ of my experience and forms its background (see De Preester’s (2007) contribution, this volume). It is, in principle, dissociable from the other components ‘‘I’’ (body-schema) and ‘‘me’’ (body-image).13 Each of these neural 9

During the neuroimaging of goal-directed, focal cognitive tasks in healthy subjects, a consistent set of regions display decreases in activation. This has been interpreted as reflecting the activity of a coherent default-mode (DM) network presumed to be active prior to engaging in the cognitive task. Because these areas of deactivation overlap with areas that become activated during tasks involving higher order active ‘‘representation,’’ reference to self, or self-focused attention, DM activity during neuroimaging of focal cognitive tasks has been interpreted as self-referential activity (e.g., Gusnard, 2005). However, reduced DM network activity in schizophrenia (Mishara, 2006) may not reflect a deficit in self-representation but a more fundamental impairment of self as totality open to an anticipated but still unknown future (i.e., reduced protention or prospective vulnerability, see Thesis 4 and (2007) for further discussion of this point). 10 The ‘‘rubber hand illusion’’ (RHI) has been used to dissociate body-schema and body-image. When a rubber-hand in view of the subject is simultaneously stroked with a paint-brush with the subject’s hand hidden from view, the subject has the uncanny feeling that the rubber hand ‘‘belongs’’ to the subject (thus, RHI). Costantini and Haggard (2007) manipulated body-schema (by altering postural position of the subject’s own not visible hand) and body-image (relative to the visible rubber hand) hand to discover that both—if unequally— contribute to RHI. Interestingly, schizophrenia patients with positive symptoms were more susceptible to the illusion and had it ‘‘five times faster’’ than healthy control subjects (Peled, Ritsner, Hirschmann, Geva, & Modai, 2000). These results suggest possible abnormalities of body-schema and body-image in schizophrenia (Mishara, 2005). 11 Unlike body-image, the (egocentric) computations of a non-conscious, short-lived, prospectively open body-schema exhibits an adaptive plasticity that is not confined to the self-enclosed (already past) unity of the predominantly visual body-image. For example, my body-schema momentarily becomes the baseball-glove catching the ball, the cane I use to walk, or the top-hat I am wearing as I automatically stoop while walking beneath a low bridge. The body schema is able to incorporate tools as if ‘‘our own effector (e.g., the hand) were elongated to the tip of the tool’’ (Maravita & Iriki, 2004, p. 79). 12 Nowak and Bullier (1997) coined the term ‘‘fast brain’’ for the fronto-parietal connectivity of the dorsal pathways which, according to the Goodale Milner model, mediate implicit visuomotor control (as well as sensori-motor transformations from other sensory modalities necessary for this control). That is, information coming from the peripheral visual field ‘‘has access to fast, direct pathways that allow for faster onset times in dorsal stream areas.’’ Moreover, we may conclude that the function of frontodorsal connectivity is the ‘‘monitoring of peripheral stimuli in general.’’ (Stephen et al., 2002, p. 3072). Remarkably, such a system of self as prospective openness, i.e., the ability to be affected by any point in its experiential field (structured by momentary, possible movement) prior to focal awareness had been anticipated by Husserl (Mishara, 2005). 13 For a discussion of how the disruption of the very feeling of being alive (and related reward-emotion processing) mediated by the proposed ‘‘mineness’’ of an interoceptive pathway may occur in schizophrenia, see Mishara, 2004.

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pathways subserving different components of self and/or their connectivity may be disrupted in schizophrenia (Mishara, 2004; Mishara, 2005). The transition and thus, seamless binding between body as subject (body-schema) and body as object (body-image) occurs in the ongoing sensori-motor integration required for prereflective bodily self-awareness (Legrand, 2006). The movement from an implicit egocentric to an explicit allocentric frame of awareness in ‘‘efferent binding’’ involves reversing frames of reference, i.e., the body-subject and body-object are each the inverse of the other.14 The ‘‘efferent binding’’ of ‘‘I move myself’’ (for Husserl, the core of self-transcendence in time) involves both conscious and non-conscious components of a perception-action cycle. Critically, the subcomponents view of self (i.e., sensori motor integration, afferent and efferent binding) differs significantly from Zahavi’s (2005) argument that the first person perspective in pre-reflective self awareness is always present in conscious experience. In this argument, the first person perspective is thought to be always present because all conscious experiences are infused ‘‘(at least tacitly)’’ with ‘‘a quality of mineness’’ or ‘‘ownership’’ of the experience (p. 19). This argument equates ‘‘I,’’ ‘‘me’’ and ‘‘mine’’ in a manner that does not allow for their separation in neuropsychiatric disorders. Additionally, the claim that we have direct reflective access to a pre-reflective self is tenuous and equates ‘‘I’’ with ‘‘me’’ (see Theses 2, 3): it does not acknowledge an ongoing (but mutually exclusive) shifting of naively experiencing and reflecting attitudes within the same subject (see Husserl, 1959; von Weizsaecker, 1968; Mishara, 2007). Moreover, there is the rather obvious objection that there is no way of knowing whether what I describe in reflection was truly there before by ruling out the possibility that the reflecting itself added or inserted those aspects I was looking for. With regard to Thesis 4, Gallagher (2005) proposes that protention or the anticipatory aspect of agency may be disrupted in schizophrenia as the sense of agency is generated ‘‘precisely in the processes that anticipate the action.’’ ‘‘In the case of delusions of control, something starts to go wrong with these anticipatory/preparatory/protentional processes . . . in terms of temporality, this is a hyper-retentionality—the subject focuses on what just happened, or the sensory feedback that registers his just-past movement.’’ (p. 3). Similarly, Binswanger proposes that the anticipatory, prospective aspect of perceptual binding (i.e., passive synthesis) is compromised in schizophrenia. He observes that his patients sometimes delusionally refer to themselves as a machine, a computer, i.e., an ‘‘apparatus’’ whose sole function is to ‘‘register’’ impressions. This concretization of metaphors of self is nevertheless an implicit way of preserving a (minimal) self in its now compromised ability to transcend the present perspective (Theses 4, 5 and 6): The image of self as ‘‘a ‘registering apparatus’ who violently subjects or ‘compresses’ her current sensory impressions to an already formed schema should not make us overlook that a ‘remnant’ of the ability to transcend—fundamental to human existence—has remained (at least formally), even if only in the monotony of a fixed schema. . .. In the place of a Gestalt-formingperception which is completely capable of flexible transitions required for sensory grasping, there enters a delusional, fixed, monotonous schema which impoverishes experience’’ (1965, p. 490, my translation).15 Following

14 Merleau-Ponty (1968) writes: By means of ‘‘reversibility . . .alone, there is passage from the ‘‘for itself’’ to the ‘‘for the Other’’ (i.e., from body for self to body for others). He adds: ‘‘There is not the For Itself and For the Other. They are each the other side of the other.’’ (p. 263). ‘‘The body sensed and the body sentient are the obverse and the reverse . . . as two segments of one sole circular course. . . which is but one sole movement in phases.’’ (p. 138, my emphasis). 15 In the phenomenological theory, the ‘‘schema’’ or ‘‘type’’ provides the principles of organization, i.e., rules for synthesis of aspects of the perceptual object in its inner structure. Object perception requires the ongoing synthesis or binding of (1) the currently experienced aspect with (2) the aspects not available to current perception and (3) a totality or unity of aspects that is never actually given in terms of the one aspect. The type or schema implicitly organizes the aspects of an object into a coherent relationship of perceptual meaning prior to its conscious perception as intentional object. Because the type is anticipatory, it provides the rules by which each partial view is in turn synthesized into an object, a totality that is never apprehended by just one view. It is not possible to experience the perceptual object in terms of all its aspects at once. The perception of a thing is relative to the standpoint of the observer. For a discussion about how the ‘‘delusional schema’’ forms automatically in passive synthesis from gaps in the continuity of experience, see Uhlhaas & Mishara, 2007. In prodromal pre-delusional schizophrenia, the passing retention becomes emphasized to fill in the ‘‘gaps.’’ ‘‘These passing retentions are brought back into the present without being able to yield any completed, identifiable meaning’’ (Mishara, 1990b, p. 275). Only later, with the ‘‘Aha-Erlebnis’’ of full-blown delusions, the seeming ‘‘insight’’ of the delusion imposes a retroactive organization on the collected, nontemporalized perceptual fragments or retentions (formed ‘‘pre-intentionally’’). To the extent that the ‘‘delusional schema’’ then becomes triggered or spontaneously emerges, it overrides current perception (Binswanger, 1965; Blankenburg, 1965). The disruption of the anticipatory or prospective (self-transcendence) function in schizophrenia is in part supported by experimental findings of abnormal interval timing, reduced default mode network activity during fMRI and deficits in common sense judgments (see Mishara, 2007).

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Von Weizsaecker (1968), Binswanger (1957, 1965) and Conrad (1958) propose discrete stages of reorganization of the perceptual field in beginning schizophrenia in which the self attempts to preserve contact with the environment but with ever increasing distortions due to underlying neurobiological disease (see Uhlhaas & Mishara, 2007). Legrand (2006) proposes that prereflective bodily self-awareness or self is the ability to experience action and perception as coherent (p. 113). For Binswanger, self as self-transcendence requires the ongoing linking of perceptual and motor sides of self—body for self and body for others - in which these aspects presuppose but also mutually exclude one another. Von Weizsaecker (1968) calls this a ‘‘Gestalt-circle,’’ or a ‘‘revolving door principle’’ which applies just as much to the ‘‘hidden unity’’ of perception and movement as to the relation between self and other(s).16 Conclusion. By providing hypotheses for further experimental study, phenomenology provides an initial systematic means for studying the subjective experience of the symptoms of schizophrenia and probing their underlying neurobiology (Mishara, 1997; Uhlhaas & Mishara, 2007; Mishara, 2007). In addition, phenomenology has contributed to the development of rating scales to assess the patient’s subjective experience of symptoms (e.g., Parnas, Handest, Jansson, & Sæbye, 2005; Parnas, Møller, Kircher et al., 2005). In this regard, Hoffman, Varanko, Gilmore and Mishara (in preparation) used a phenomenological approach to develop a questionnaire to examine schizophrenia patients’ subjective experience of their ‘‘voices.’’ Patients were asked which (subjective) experiential features allowed them to distinguish ‘voices’ from ordinary verbal thought. In this brief commentary, I have provided an alternative phenomenological account to the hyperreflexivity model (described by Cermolacce et al., this volume) as a possible explanation of disrupted self-experience in schizophrenia: compromised perceptual and efferent binding and/or sensori motor integration on a pre-attentional level may lead to impaired experience of self in schizophrenia. In providing this alternative, it is possible that I raise more questions than I answer. But that may be the purpose of a brief commentary. References Binswanger, L. (1957). Schizophrenie. Pfullingen: Neske. Binswanger, L. (1965). Wahn. Pfullingen: Neske. Blankenburg, W. (1965). Die Verselbstaendigung eines Themas zum Wahn. Jahrbuch fu¨r Psychologie, Psychotherapie und Medizinische Anthropologie, 13, 137–164. Blanke, O., Ortigue, S., Landis, T., & Seeck, M. (2002). Stimulating illusory own-body perceptions. Nature, 419, 269–270. Conrad, K. (1958). Die beginnende Schizophrenia, Versuch einer Gestaltanalyse des Wahns. Stuttgart: Thieme Verlag. Costantini, M., & Haggard, P. (2007). The rubber hand illusion: Sensitivity and reference frame for body ownership. Consciousness and Cognition, 16, 229–240. De Preester, H. (2007). The deep bodily origins of the subjective perspective: Models and their problems. Consciousness and Cognition, 16, 604–618. Foa, Edna B., & Riggs, David S. (1993). Posttraumatic stress disorder and rape. In J. M. Oldham, M. B. Riba, & A. Tasman (Eds.). Review of Psychiatry (Vol. 12). Washington, DC: American Psychiatric Press. Frith, C. D. (2004). Schizophrenia and theory of mind. Psychological Medicine, 34, 385–389. Fuster, J. M. (2006). The cognit: a network model of cortical representation. International Journal of Psychophysiology, 60, 125–132. Gallagher, S. (2005). Protention, schizophrenia, and gesture. Panel on body, affect, and time in language: a neurophenomenological approach to psychotic and other non-aphasic language disorders. In Conference on interacting bodies—corps en interaction. International Society of Gesture Studies (ISGS), Lyon, France (June 15–18 2005). Gallagher, S. (2007). Sense of agency and higher-order cognition: Levels of explanation for schizophrenia. Cognitive Semiotics, 1, 33–48. Gusnard, D. A. (2005). Being a self: Considerations from functional imaging. Consciousness and Cognition, 14, 679–697. Hoffman, R. E., Varanko, M., Gilmore, J., Mishara, A.L. (in preparation). When and how persons with schizophrenia differentiate hallucinated voices from their ordinary verbal thoughts. Husserl, E. (1959). Erste Philosophie (1923/24). II. Theorie der Phaenomenologischen Reduktion. The Haag: Martinus Nijhoff. Husserl, E. (1966). Analysen zur passiven Synthesis aus Forschungsmanuscripten 1918–1926. The Hague: Martinus Nijhoff. Klein, T. A., Endrass, T., Kathmann, N., Neumann, J., von Cramon, D. Y., & Ullsperger, M. (2007). Neural correlates of error awareness. Neuroimage, 34, 1774–1781. Legrand, D. (2003). How not to find the neural signature of self-consciousness (Commentary on Newen & Vogeley). Consciousness and Cognition, 12, 544–546.

16 Viktor Von Weizsaecker’s work (1968) had profound impact on the German-speaking phenomenological approaches to neuropsychiatric disorders reviewed in this commentary. However, he is not well-known in the literature in English. An exeption is Fuster, 2006.

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