Based on recent phenomenological, development-psychologically and neuroscientific concepts, proponents of an ―ipseity-disturbance‖ as the basis of AVHs distinguish between a basic and a personal self (Fuchs, 2012b). The basic (or minimal) self (ipseity) designates an implicit, pre-reflective sense of ―mineness‖ that is thought to be intrinsic to all (normal conscious) experience, remaining intact even in cases of loss of autobiographic memory, whereas the personal self is thought to constitute itself in the relation to others from the second year of life (Fuchs, 2012b). (We will examine Fuchs‘ (2005, 2013b) account in more detail shortly.) This sense of self is called ―pre-reflective‖ as it is assumed that it is not necessary to reflect upon your conscious experience being your experience, but that it is always already given as yours. In the reviewed studies, ―basic sense of self‖, ―basic self- awareness‖ or ―ipseity‖ are interchangeable terms. Some of the authors propose that the basic self-awareness is dynamic and may be influenced by factors such as stress (Henriksen et al., 2015). Let us consider the proposed accounts more indepth.
6.2.3.1 Sass and Parnas’ (2003) account of schizophrenia as a self-disorder
In a seminal paper, it was proposed that AVHs can be understood within the context of schizophrenic disorders as disorders of the basic self or ―ipseity disturbance‖ (Sass & Parnas, 2003, p. 427). With ipseity, the authors denote the ―the experiential sense of being a vital and self-coinciding subject of experience or first person perspective on the world‖ (Sass & Parnas, 2003, p. 428). Its disturbance, the authors argue, goes along with ―complementary distortions of the act of awareness‖ (p.428), namely with what they call ―hyper-reflexivity‖23 and diminished ―self-affection‖. This ―hyper-reflexivity‖ may manifest itself in becoming aware of aspects of one‘s actions that usually remain in the experiential background and is considered as a compensatory reaction to the postulated ipseity-disturbance.
In order to illustrate that, they cite a patient of McGhie and Chapman (1961): ―[…] I take more time to do things because I am always conscious of what I am doing. If I could just stop noticing what I am doing, I would get things done a lot faster‖ (pp. 107-108, in Sass & Parnas, 2003, p.434).
With diminished self-affection, the authors mean ―a weakened sense of existing as a vital and self-coinciding source of awareness and action‖ (Sass & Parnas, 2003, p. 427). Self- affection or some kind of self-awareness, for the authors, constitutes a condition for an
23 Note, that one can distinguish operative hyper-reflexive processes that are assumed to be a rather automatic consequence of
87
experience to be conscious. ―Hyper-reflexivity‖ and ―diminished self-affection‖, the authors propose, constitute complementary facets of the proposed fundamental alterations in ipseity in schizophrenia.
The authors propose that in the condition of schizophrenia one finds an ―increasing gap between the sense of self and the flow of consciousness‖ (Sass & Parnas, 2003, p. 432). Inner speech and other mental processes are assumed to ―no longer [be] permeated with the sense of selfhood‖ and instead to ―become more like introspected objects, with increasingly reified, spatialised, and externalised qualities‖ (Sass & Parnas, 2003, p. 432). AVHs, thus, in the proposed account are conceptualised as based on ―normal‖ cognitive phenomena that, due to a disturbed basic self-experience, are experienced in a transformed manner. The authors refer especially to commenting voices and conversing voices
This transformed experience has been described in terms of an objectification of inner dialogue.
6.2.3.2 AVHs as “objectified inner speech”: Stanghellini and Cutting’s (2003) account
Stanghellini and Cutting (2003) argue that the proposed ―ipseity-disturbance‖ in schizophrenia ultimately may lead to an objectification of ―inner dialogue‖. They assume that inner dialogue which they define as ―talking to oneself‖ (Stanghellini & Cutting, 2003, p. 126) is fundamental for self-conceptualisation and dominates one‘s experience of oneself. At the same time, the authors assume that the process of inner dialogue normally remains subconscious. The authors maintain that a defining feature of inner dialogue is that ―in it we experience at the same time a sense of unity and a sense of duality‖ (Stanghellini & Cutting, 2003, p. 123). This inner dialogue is assumed to become conscious in AVHs, thereby becoming like an object. To put it in the authors‘ words, in the case of AVHs ―awareness no more focuses on the outcome of inner dialogue (i.e., self- conceptualisation), but on its very process (i.e., two characters arguing with each other)‖ (Stanghellini & Cutting, 2003, p. 126). The morbid objectification of inner dialogue that, according to the authors, occurs in AVHs is not assumed to be an additional process of the postulated ipseity-disturbance and the compensatory hyper-reflexivity in schizophrenia. Rather, the authors consider it as an ―extreme manifestation of these two basic phenomena‖ (Henriksen et al., 2015, p. 124). In the case of AVHs, the sense of unity usually inhabiting inner dialogue is assumed to be lost.
Summarising, Stanghellini and Cutting (2003) propose that a disturbance of ipseity goes along with a type of hyper-reflexivity that leads to a ―detachment from ‗myness‘ an
88
agency‖ (p.125) and finally to the proposed morbid objectification of inner dialogue and thus to the experience of AVHs.
6.2.3.3 AVHs as “objectified inner speech”: Henriksen et al.’s (2015) account
Henriksen, Raballo, and Parnas (2015) introduce the notion of ―primordial presence‖ to clarify the notion of ―pre-reflective self-awareness‖. In the words of the authors, the notion of ―primordial presence‖ means that a person‘s ―pre-reflective immersion in the world‖ (p. 173) and her pre-reflective self-awareness are ―in fact, inseparable‖ (p.173). What is new here is that the proposed ―pre-reflective self-awareness‖ is coupled with a person‘s situatedness in the world.
The authors argue that the formerly proposed alterations of ―pre-reflective self- awareness‖ (or using the new notion: ―primordial presence‖) involve also changes in how space is experienced and an ―objectification‖ of inner speech, which may ultimately lead to AVHs. More precisely, they assume that the disturbance of ―primordial presence‖ allows that a ―sort of persistent, inner space‖ (Henriksen et al., 2015, p. 174) is construed in which, for example, thoughts are experienced as having spatial qualities.
They then conceptualise AVHs as arising from ―inner speech dialogues between thoughts that have acquired quasi-acoustic qualities‖ (Henriksen et al., 2015, p. 175). It remains open how thoughts can dialogue and why and how they acquire these ―quasi- acoustic‖ properties. Inner speech, thereby, in accordance with Stanghellini and Cutting (2003) is defined as ―implicit or silent medium for self-presentation‖ (Henriksen et al., 2015, p. 175).
Instead of taking AVH as abnormal perceptions, the authors regard them as cognitive phenomena, a proposal that is rooted in their observation that ―hallucinatory voices seem to be given to patients in a sort of direct inner intuition […] rather than in a sensory perception (…)‖ (Henriksen et al., 2015, p. 167). They acknowledge that with the mechanism they propose they cannot account for AVHs that ―occur quite suddenly or acutely‖ (p.176).
The authors describe the gradual self-alienation referring to three case vignettes from which they derive their account of AVH development. They hypothesise that increased thought pressure24 combined with a reduced ability to distinguish auditory imagination from thoughts may lead to a state in which the patients do not know ―if they, so to say, thought their thoughts or listened to them‖ (Henriksen et al., 2015, p. 171). In a second step, the authors report, their patients began to hear their pressing thoughts as spoken in their own voice. In
89
terms of content those thoughts ranged from self-instructions and self-commands to self- conversations. Finally, ―frank‖ AVH were characterised by ―a loss of feeling that the heard thoughts belonged to the listening subject‖ (Henriksen et al., 2015, p. 171).
6.2.3.4 Voice-hearing in schizophrenia as disembodiment of the basic self – Fuchs’ (2005a) account
Fuchs (2005a) has described the alterations of the basic self-experience in terms of disembodiment. This idea is based on the assumption of a strong interdependence between pre-reflective self-awareness and corporality (Leiblichkeit). The basic self, as the author understands it, is grounded on the body as ―lived medium‖ through which we direct ourselves to the world (perceive/act)25. Similarly, Sass and Parnas (2003) assume that a tacit awareness of proprioceptive and kinaesthetic sensations serves as the medium of pre-reflective self- awareness26. The sense of agency is assumed to be based on such proprioceptive and kinaesthetic sensations as well as ―the bodily sensation of being able to move (one‘s own body)‖ (Fuchs, 2005a, p.96)27
. The basic self is further assumed to include a basal temporal self-continuity (Fuchs, 2012b), an idea to which we will come back shortly.
Fuchs (2012b) differentiates between three dimensions of a basic self: the primary bodily self, the ecological self, and the social self (see also Figure 13). This conception of the basic self indicates that already one‘s self-experience is not isolated but intertwined with one‘s ecological and social environment.
In schizophrenia, the author proposes, a gradual alteration of the bodily self-experience occurs. More specifically, the author assumes that the basic self is weakened and a disembodiment in the sense of a loss of the natural corporal embedding in the body and the world occurs (Fuchs, 2012b). To put it in the author‘s words, what characterises the condition of schizophrenia is a ―divorce of the self from its body‖ (Fuchs, 2005a, p. 105). This disembodiment of the basic self, consequently, comes along with disturbances on all dimensions and levels of self-experience. Regarding the dimension of the ecological self, due to the postulated disembodiment the body, that in normal experience remains in the
25 At this point it is worth noting that in phenomenology distinguishes between the lived body (Leib) or body-subject and the
physical body (Körper) or body-object. ―The first is the body experienced from within, my own direct experience of my body in the first-person perspective, myself as a spatiotemporal embodied agent in the world, the second is the body thematically investigated from without, as for example by natural sciences as anatomy and physiology, a third person perspective‖ (Northoff & Stanghellini, 2016, p. 8)
26 This focus on the bodily (leiblichen) aspects of schizophrenia is what distinguishes Fuchs‘ account of schizophrenia from,
for example, Sass and Parnas‘ account on which, amongst others, Fuchs builds.
90
background or is transparent normal experience is assumed to be explicated (Fuchs, 2005a)28. This explication is further assumed to come along with an alienation of perception and action. Moreover, the ipseity-disturbance is assumed to affect the social dimension of the basic self (i.e., an impairment of the intersubjective constitution of the life-world) and ultimately also the level of the personal self, as it is based on the basic self (Fuchs, 2012b).
Figure 13 Schematic illustration of the postulated dimensions of the basic self, as well as its relation with the
personal self (Fuchs, 2012b).
Within this theoretical framework, AVHs are considered to be due to the externalisation of self-generated activity that has become so alienated that is no longer experienced as such: the experience of inner speech is proposed to no longer pervaded by a sense of ―mineness‖ and thus experienced as externalised.