ORIGINAL ARTICLE Examination of Anomalous Self-Experience Initial Study of the Structure of Self-Disorders in Schizophrenia Spectrum Andrea Raballo, MD*Þþ and Josef Parnas, MD, DrMedSci*Þ Abstract: A growing body of evidence points to the clinical and heuristic value of anomalous subjective experiences (ASEs) for the characterization of schizophrenia spectrum vulnerability and early detection purposes. In particular, a subgroup of ASEs, entailing basic disorders of self-awareness (self-disorders [SDs]), has been shown to constitute a core feature of both clinically overt and latent (schizotaxic) spectrum phenotypes. However, a major limitation for the translational implementation of this research evidence has been a lack of assessment tools capable of encompassing the clinical richness of SDs. Here, we present the initial normative data and psychometric properties of a newly developed instrument (Examination of Anomalous Self-experience [EASE]), specifically designed to support the psychopathological exploration of SDs in both research and ‘‘real world’’ clinical settings. Our results support the clinical validity of the EASE as a tool for assessing anomalies of self-awareness (SDs) and lend credit to the translational potential of a phenomenological exploration of the subjective experience of vulnerability to schizophrenia. Key Words: Self, vulnerability, subjective psychopathology, phenomenology, assessment, psychiatric interview. (J Nerv Ment Dis 2012;200: 577Y583) A nomalous subjective experiences (ASEs) are increasingly acknowledged as an important psychopathological domain for the characterization of schizophrenia spectrum conditions (Koren et al., 2010; Moller and Husby, 2000; Nelson and Yung, 2010; Parnas and Handest, 2003; Parnas et al., 2005a, 2003; Raballo and Maggini, 2005; Raballo and Parnas, 2011; Raballo et al., 2001; Schultze-Lutter et al., 2007; Skodlar and Parnas, 2010). Recently rediscovered in contemporary psychiatry, ASEs have been thoroughly investigated in continental European psychiatry for more than a century (see Parnas and Handest, 2003, for a comprehensive review). Specifically, characteristic qualitative changes of subjective experience were considered as intrinsic features of the very Gestalt of spectrum disorders (Berze, 1914; Blankenburg, 1971; Jaspers, 1962; Schneider, 1950). Jaspers (1962, p. 95) emphasized a ‘‘diminished awareness of being and of one’s own existence’’ as the essential background for the articulation of primary, that is, schizophrenic, delusion. In a similar vein, Schneider (1950, p. 100) placed at the heart of his concept of First Rank Symptoms a ‘‘radical qualitative change in the thought processes’’ in the sense of a transformation of the form of consciousness with a diminished sense of first personal givenness *Danish National Research Foundation: Center for Subjectivity Research, †Department of Psychiatry, Psychiatric Center Hvidovre, University of Copenhagen, Copenhagen, Denmark; and ‡Psychiatric Intensive Care Unit, Department of Mental HealthYAUSL Reggio Emilia, Emilia-Romagna Regional Health System, Reggio Emilia, Italy. Send reprint requests to Andrea Raballo, MD, Danish National Research Foundation: Center for Subjectivity Research, University of Copenhagen, Njalsgade 140-142, DK-2300 Copenhagen S, Denmark. E-mail: anr@hum.ku.dk. Copyright * 2012 by Lippincott Williams & Wilkins ISSN: 0022-3018/12/20007-0577 DOI: 10.1097/NMD.0b013e31825bfb41 The Journal of Nervous and Mental Disease of experience (Ichheit) and a disturbed sense of mineness of experience (Meinhaftigkeit) (Berze, 1914; Nordgaard et al., 2008; Parnas and Handest, 2003; Schneider, 1950). On a phenomenological level, a diminished sense of selfpresence results in an increasing distance between the sense of self and the stream of the lived experiences, which was very accurately commented by Jaspers (1962, p. 122): ‘‘The remarkable thing about this particular phenomenon is that the individual, though he exists, is no longer able to feel he exists. Descartes’ ‘‘cogito ergo sum’’ (I think therefore I am) may still be superficially cogitated but it is no longer a valid experience.’’ Recent empirical studies with a phenomenological orientation support these original observation conditions (Koren et al., 2010; Moller and Husby, 2000; Nelson and Yung, 2010; Parnas et al., 2005a, 2003, 1998; Raballo and Maggini, 2005; Raballo and Parnas, 2011; Raballo et al., 2001; Schultze-Lutter et al., 2007; Skodlar and Parnas, 2010) and point to the crucial psychopathological importance of exploring formal/structural alterations of experience and consciousness (Nordgaard et al., 2008; Parnas and Handest, 2003). Indeed, ASEs encompass a broad range of subtle, nonpsychotic disturbances of the awareness of one’s own mental activity, of the external world, and of the lived body, which require a phenomenological approach to be appropriately elicited and reliably assessed. The Examination of Anomalous Self-experience (EASE) (Parnas et al., 2005b) was specifically developed to support the systematic exploration of self-disorders (SDs), which are nonpsychotic experiential anomalies in the basic sense of being a selfpresent embodied subject immersed in the world. Despite their intrinsic elusiveness, this subset of ASEs is susceptible to self-description (Kean, 2009; Saks, 2007) and can be assessed within the context of a psychopathological interview (Moller and Husby, 2000; Mundt, 2005; Parnas and Handest, 2003 ) with good to excellent reliability (Moller et al., 2011; Vollmer-Larsen et al., 2007). The construction of the EASE (Parnas et al., 2005b) was based on a close integration of pluriennial clinical experience in the diagnosis and treatment of schizophrenia spectrum conditions, empirical epidemiological and psychopathological studies (including psychopathological precursors identified in the Copenhagen High Risk Study) (Parnas et al., 1993), conceptual insights from phenomenological philosophy (Husserl, 1982; Zahavi, 1999) and continental psychopathology (Blankenburg, 1971; Conrad, 1958; Jaspers et al., 1962; Minkowski, 1953), as well as existing psychopathological scales modelled on Jaspersian subjective phenomenology (Gross et al., 1987; Huber, 2002). Concretely, the EASE explores five main domains of items that are grouped according to clinical common sense, to ensure a coherent flow of the interview while at the same time facilitating the systematic exploration of similar sets of experiences. Those thematic sets are the experience of the stream of consciousness (domain 1), the sense of presence (domain 2), bodily experiences (domain 3), the sense of self-demarcation (domain 4), and existential reorientation (domain 5). & Volume 200, Number 7, July 2012 www.jonmd.com Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 577 The Journal of Nervous and Mental Disease Raballo and Parnas From a phenomenological perspective, although different in their thematic content, all these experiences can be seen as reflecting and reiterating a profound change in the structure of subjectivity. That is, they all share a common formal feature: a fundamental shift in the sense of being a self-coinciding subject, endowed with a stable first-person perspective and vitally engaged in the world. For example, distortions at the level of the stream of consciousness are associated with a change in the tacit sense of naturalness of mental activity, so that the experience of thinking might be altered (e.g., thoughts might feel anonymous or spatialized or acquire a quasi-sensorial concreteness) and the increasing experiential gap between the self and mental content might exacerbate introspective self-monitoring. Similarly, disturbances of the sense of presence interfere with the usually unproblematic immersion in the world of everyday activities and relations, so that the subject’s vital and pragmatic engagement is altered. Likewise, disturbances of the sense of corporeality (i.e., bodily experiences) are characterized by a growing experiential distance between the self and bodily experience, so that the body is not inhabited and lived through but rather scrutinized as an object. Along the same phenomenological lines, disturbances of self-demarcation are characterized by the inability to distinguish the self from the other (transitivistic experiences), whereas existential reorientation refers to the development of idiosyncratic preoccupation with supernatural and metaphysical themes accompanied by solipsistic feelings of centrality and uniqueness. Overall, these domains are meant to capture different (i.e., thematically nonoverlapping) phenomenological aspects of an overarching, global change in the structure of experience and awareness (Parnas and Handest, 2003; Sass and Parnas, 2003; Parnas et al., 2005a) while at the same time ensuring a systematic exploration of its manifold manifestations (see Appendix 1). The aim of the current study is twofold. First, we present the normative data of the first, hospital-based sample assessed with the EASE by its own authors. Second, we explore some of its psychometric properties. Specifically, we tested the internal consistency, the domain intercorrelation and aggregation, and finally, the association with clinically meaningful aspects of concurrent and external validity (i.e., major psychopathological dimensions and premorbid features). Because, due to their pervasive experiential quality, SDs manifest phenomenologically coherent facets of an overarching Gestalt change in the patient’s field of consciousness (Parnas and Handest, 2003; Sass and Parnas, 2003) rather than mutually independent sets of symptoms, we expected to find high intercorrelation among the EASE domains. For the same reason, despite the difference in the thematic content of the domains, we expected a monofactorial distribution in the principal component analysis (PCA). As corollary experimental hypothesis, in line with previous nonEASE-based research on SDs (Parnas et al., 2005a, 2003; Raballo and Maggini, 2005; Raballo and Parnas, 2011; Raballo et al., 2001), we expected to find a higher EASE score in schizophrenia spectrum versus nonspectrum conditions. METHODS Sample The sample consisted of 36 patients admitted for the first time to a Department of Psychiatry (at Hvidovre Hospital, an inpatient facility serving the inner city of Copenhagen, with a catchment area of about 130,000 inhabitants) between May 2004 and September 2005. The participants, all admitted with a suspected psychotic condition (affective or nonaffective), were enrolled in the final phase of the development of the EASE (early 2004) for the main purpose of calibrating the instrument through extensive discussion among the authors and testing its clinical feasibility in the context of the hospital clinical care pathways. 578 www.jonmd.com & Volume 200, Number 7, July 2012 Patients with organic brain disorder, severe substance abuse as a primary diagnosis, or as a clinically dominating comorbid condition were excluded from the study. Likewise, severely aggressive or involuntarily admitted patients were not included because of ethical concerns or because they were considered to be unable to undergo the full examination. Assessment Procedure During their hospitalization, the patients underwent a comprehensive psychiatric evaluation eliciting biographic, social, and psychopathological information in a semistructured way. The EASE was embedded in such an extensive interview frame that included, among others, the Operational Criteria diagnostic checklist (McGuffin et al., 1991), the mental state examination from the Schedules for Clinical Assessment in Neuropsychiatry (Wing et al., 1990), and the Positive and Negative Syndrome Scale (PANSS; Kay et al., 1987). The interview provided detailed information on preadmission features (e.g., chronology of emergent symptoms, age at first contact with mental health facilities, context, and dates of potential prehospital diagnosis). The interview sessions were conducted by a senior consultant psychiatrist and coauthor of the scale (Jørgen Thalbitzer) in an intensive mutual exchange with the other authors (nearly all senior clinicians with several years of experience in the diagnosis and treatment of schizophrenia spectrum conditions). The average duration of the entire interview was between 1.5 and 3 to 4 hours, with the EASE covering approximately half of that time. The study was approved by the relevant Medical Ethics Committee, and the patients were recruited upon written informed consent. Study Variables Diagnosis Diagnostic assignment was made according to the International Classification of Diseases, 10th Revision (ICD-10), by consensus between the treating clinicians and the interviewer. Self-Disorders SDs were explored through the EASE, a checklist providing a framework for phenomenological-descriptive assessment of patients’ subjective anomalies of experience (Parnas et al., 2005b). The EASE contains the following main sections or domains: (1) disturbances of cognition and stream of consciousness (such as experiences of thought interference, thought block, thought pressure, and spatialization of thinking [e.g., sensing the thoughts as spatially located objects]), (2) disturbances of self-awareness and presence (such as unstable firstperson perspective, lack of basic, immediate sense of identity or ‘‘meness,’’ diminished self-presence), (3) anomalous bodily experiences (such as somatic depersonalization and sense of mind-body misfit or disconnection), (4) demarcation/transitivism (such as passivity mood and various manifestations of failing of self-world boundary), and (5) existential reorientation (such as development of quasi-metaphysical world views or solipsistic experiences). For the purpose of the analysis, we looked only for the presence or absence (not severity or duration) of the items from the five domains of EASE and explored the latter as dimensions (i.e., counting up the items rated as present). This was done to ensure comparability with previous and ongoing studies on the EASE and analogue instruments (Maggini and Raballo, 2004; Moller et al., 2011; Parnas et al., 2003; Raballo and Maggini, 2005; Skodlar and Parnas, 2010; Vollmer-Larsen et al., 2007). Operatively, we dichotomized the Likert severity scores of the EASE, counting 0 and 1 (absent or questionably preset) as absent and 2, 3, and 4 (i.e., mild, moderate, and severe) as present. The detailed item list is reported in Appendix 1. All EASE interviews were audio- and/or videotaped for transcription. * 2012 Lippincott Williams & Wilkins Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. The Journal of Nervous and Mental Disease & Volume 200, Number 7, July 2012 General Psychopathology We used the PANSS to characterize the severity of the clinical psychopathology (Kay et al., 1987). PANSS-derived subscores were calculated according to van den Oord et al. (2006) to map six latent components: the typical five (i.e., Negative, Positive, Excited/Activation, Anxious-Depressed/Dysphoric, and Disorganized) and a sixth dimension, labelled Withdrawn (which includes Apathy/Social Withdrawal, Active Social Avoidance, and Emotional Withdrawal). We opted for such model because it offers a clinically more nuanced grasp of relevant symptom components. Premorbid Variables We calculated three chronological indexes (see the legend of Table 3 for computational detail) to estimate previous mental health history. Those indexes were years since first contact with a mental health service (i.e., a proxy for the length of formal clinical ‘‘caseness’’ status), years since first self-reported symptom (i.e., a proxy for the duration of illness), and the latency between the first reported symptoms and the specialistic referral (i.e., a rough estimate of the duration of untreated illness, which is indicated as ‘‘years before treatment’’ in the table). Finally, we derived a combined index of reduced socio-professional adjustment. Statistical Analyses Chi-square, Goodman-Kruskal gamma (i.e., a measure of association for ordinal data), or Welch’s statistic were used to analyze demographic and clinical characteristics of the sample, stratified according to the ICD-10 in three subgroups (i.e., schizophrenia, schizotypal disorder, and nonschizophrenia spectrum conditions). Cronbach’s alpha coefficient was used to evaluate internal consistency. PCA was used to assess the presence of common latent variables. We circumscribed the PCA to the EASE domains because the small sample size was incompatible with an item-level analysis. Both the measures of the sampling adequacy and factorability (i.e., Kaiser-Meyer-Olkin Self-Disorders in Schizophrenia value, 0.810; Bartlett’s test of sphericity: W2 = 95.241, df = 10, p G 0.00001) confirmed the applicability of PCA to the data set. Spearman’s rho analysis was used to explore the intercorrelation between EASE domains and to assess the relationship between the EASE, the PANSS subscores, and relevant clinical/sociodemographic variables (in particular premorbid indicators). RESULTS The sample characteristics are presented in Table 1. The diagnostic subgroups (schizophrenia, schizotypal disorder, and nonschizophrenia spectrum) differ in terms of socio-occupational adaptation, global severity of psychopathology (PANSS total score), and SDs (EASE total score). No differences were found concerning age, age at first contact, and age at first psychopathological symptom. The EASE shows good to excellent (i.e., 0.85Y0.90) internal consistency across the diagnostic subgroups and an overall excellent alpha (90.90) in the whole sample. Corresponding PANSS alpha coefficients are provided as a comparison. Further analyses of the EASE domains are provided in Table 2. Correlations between EASE total score and single domain scores, as well as interdomain correlations, ranged from moderate to very strong. In both cases, the highest coefficients concerned the first three domains (i.e., cognition and stream of consciousness, self-awareness and presence, bodily experiences), which were also the ones with the highest internal consistency. The PCA of the EASE domains yielded a one-factor solution accounting for 65.9% of the total variance. Such solution was retained on the basis of the criteria of joint eigenvalues greater than 1 and Cattell’s scree test. Factor loadings were 0.91 (self-awareness and presence, EASE domain 2), 0.90 (cognition and stream of consciousness, EASE domain 1), 0.86 (bodily experiences, EASE domain 3), 0.74 (existential reorientation, EASE domain 5), and 0.61 (demarcation/transitivism, EASE domain 4). TABLE 1. Characteristics of the Study Sample and Reliability Scores Sample Mean (SD) n Sex (M/F) Age, yrs Age at first contact, yrs Age at first symptom, yrs PANSS, total score EASE, total score Reduced socio-professional adjustment, nd Absent Moderate Severe Cronbach’s > PANSS EASE Schizophrenia Mean (SD) Range Nonspectrum Disordersa Range Mean (SD) 18Y42 12Y36 7Y25 32Y64 0Y40 19 7/12 25.7 (6.4) 18Y41 21.6 (6.4) 12Y34 13.9 (3.3) 9Y24 55.9 (6.8) 42Y64 21.4 (9.6) 8Y40 8 6/2 28.0 (4.6) 19Y33 25.0 (6.0) 16Y32 13.8 (5.1) 7Y23 48.1 (7.6) 39Y59 17.0 (7.2) 9Y30 9 4/5 27.3 (8.3) 20Y42 22.6 (6.4) 14Y36 15.0 (5.2) 9Y25 39.3 (9.0) 32Y60 5.7 (5.1) 0Y16 19 11 6 6 8 5 5 2 1 8 1 0 F (0.699), p G 0.001 0.80 0.93 0.52 0.90 0.65 0.85 0.89 0.85 Y Y 36 17/19 26.6 (6.5) 22.6 (6.3) 14.1 (4.0) 49.4 (10.2) 16.5 (10.4) Range Schizotypal Disorder Mean (SD) Range Statistic, p W2 (3.326), p = 0.190 Welch’s F (0.531), p = 0.598 Welch’s F (0.847), p = 0.447 Welch’s F (0.134), p = 0.876 Welch’s F (10.559), p = 0.002b Welch’s F (16.899), p G 0.001c a This group is constituted by subjects with ICD-10 diagnosis of affective disorder (three major depressive disorders, recurrent, moderate [code f33.1]; 2 major depressive disorders, single episode, moderate [code f32.1]; two major depressive disorders, single episode, mild [code f32.0], and one cyclothymic disorder [code f34.0]). b Post hoc analysis (Bonferroni correction): nonspectrum G schizophrenia. c Post hoc analysis (Bonferroni correction): nonspectrum G schizotypal disorder, schizophrenia. d Reduced socio-professional adjustment (before the onset of the disorder): absent, no previous reduction of social and/or occupational adjustment; moderate, reduced adjustment, either social or professional; severe, combined poor social and professional. PANSS indicates Positive and Negative Syndrome Scale; EASE, Examination of Anomalous Self-experience. * 2012 Lippincott Williams & Wilkins www.jonmd.com Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 579 The Journal of Nervous and Mental Disease Raballo and Parnas & Volume 200, Number 7, July 2012 TABLE 2. EASE Domains: Internal Consistency, Descriptives, and Correlational Matrix EASE 1 EASE 2 EASE 3 EASE 4 EASE 5 No. of Items Range Mean (SD) Cronbach’s > EASE 1 EASE 2 EASE 3 EASE 4 EASE 5 EASE Total 17 18 9 5 8 0Y15 0Y14 0Y7 0Y3 0Y6 5.8 (3.5) 5.5 (3.7) 2.0 (2.0) 1.4 (1.1) 1.9 (1.8) 0.80 0.83 0.74 0.25a 0.65b Y 0.852** Y 0.699** 0.709** Y 0.365* 0.470** 0.542** Y 0.582** 0.626** 0.485** 0.430** Y 0.906** 0.946** 0.821** 0.573** 0.740** a Alpha increases to 0.62 removing two items (4.3 and 4.5). Alpha increases to above 0.70 removing one item (5.1). *p G 0.05 (two tailed). **p G 0.01 (two tailed). EASE domains: (1) cognition and stream of consciousness, (2) self-awareness and presence, (3) bodily experiences, (4) demarcation/transitivism, and (5) existential reorientation. EASE indicates Examination of Anomalous Self-experience. b Table 3 provides the correlational analyses between SDs (quantitatively described by EASE total and domain subscores), clinical symptom dimensions, sociodemographic variables, and premorbid indexes. EASE score strongly correlated with the severity of global psychopathology and, selectively, with schizophrenia-specific PANSS dimensions, namely, Positive, Negative and Withdrawal. A moderate, positive correlation was also present with reduced socioprofessional adjustment. No significant association was found between EASE and estimates of duration of psychopathology. The correlational pattern of the EASE domains’ subscores was basically isomorphic to the one exhibited by the total EASE score. DISCUSSION The results of the present study extend previous findings on the clinical relevance of SDs in schizophrenia spectrum conditions (Koren et al., 2010; Nelson and Yung, 2010; Parnas et al., 2005a; Raballo and Parnas, 2011; Raballo et al., 2001; Skodlar and Parnas, 2010) and indicate that the EASE (Parnas et al., 2005b; Mundt, 2005) is a useful instrument for the assessment of SDs. The EASE showed satisfactory psychometric features, with a good to excellent internal consistency. With the exception of domain 4 (transitivism/demarcation), the internal consistency was satisfactory even at a single domain level and proved to be substantially stable across the diagnostic subgroupings. Notably, as a further feature of cross-validation, the EASE total and subscores are nearly identical to those obtained in an independent sample of schizophrenia inpatients examined in Slovenia (Skodlar and Parnas, 2010). As expected, all five EASE domains were highly intercorrelated, suggesting that they plausibly measure components of a common psychopathological construct. Similarly, the monofactorial solution of the PCA also indicates that the EASE domains trace a common latent variable. This supports the view that these domains are best conceived as interrelated expressions of a Gestalt change in the patient’s field of awareness rather than as independent dimensions (Parnas and Handest, 2003; Sass and Parnas, 2003). With respect to SDs, we replicated the distribution pattern previously reported (in the context of non-EASE-based studies) in both genetically high-risk (Raballo and Parnas, 2011; Raballo et al., 2001) and clinical (Parnas et al., 2003; Parnas et al., 2005a) populations. That is, nonspectrum patients showed lower levels of SDs, whereas no statistically significant differences were found between schizotypal disorder and schizophrenia patients. The correlational analyses with clinical and premorbid indicators corroborate several assumptions concerning the psychopathological relevance of SDs. First, the correlations between EASE and TABLE 3. Correlational Analysis Between SDs, Psychopathological Dimensions, Sociodemographic Variables, and Socio-Professional Adjustment PANSS total PANSS Negative PANSS Positive PANSS Excited PANSS Anxious-Depressive PANSS Disorganized PANSS Withdrawn Age (yrs) Years since first contacta Years since first symptomb Years before treatmentc Reduced socio-professional adjustment EASE Total EASE 1 EASE 2 EASE 3 EASE 4 EASE 5 0.647** 0.428** 0.607** 0.013 0.201 0.267 0.440** j0.175 j0.094 0.105 0.075 0.405* 0.616** 0.453** 0.514** 0.030 0.230 0.198 0.494** j0.225 j0.044 0.018 j0.018 0.311 0.561** 0.333* 0.509** j0.027 0.214 0.218 0.398* j0.133 j0.059 0.209 0.122 0.364* 0.668** 0.384* 0.461** 0.125 0.300 0.309 0.302 j0.241 j0.129 j0.054 0.067 0.352* 0.455* 0.324 0.507** j0.008 0.181 0.303 0.404* j0.258 j0.127 0.039 0.080 0.338* 0.680** 0.334* 0.670** j0.047 j0.127 0.395* 0.335* 0.087 j0.094 0.194 0.093 0.403* a Age at the assessment j age at first contact. Age at the assessment j age at first symptom. Age at first contact j age at first symptom. *p G 0.05 (two tailed). **p G 0.01 (two tailed). EASE domains: (1) cognition and stream of consciousness, (2) self-awareness and presence, (3) bodily experiences, (4) demarcation/transitivism, and (5) existential reorientation. SDs indicates self-disorders; EASE, Examination of Anomalous Self-experience; PANSS, Positive and Negative Syndrome Scale. b c 580 www.jonmd.com * 2012 Lippincott Williams & Wilkins Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. The Journal of Nervous and Mental Disease & Volume 200, Number 7, July 2012 those PANSS subscores that reflect diagnostic symptoms of schizophrenia (Positive, Negative, and Withdrawal) confirm a rather elective association of SDs with some of the most spectrum-specific psychopathological dimensions. Second, a correlation with a reduced premorbid socio-professional adjustment indicates a possible external clinical impact of SDs or may point to a shared neurodevelopmental root for both sets of variables (Parnas et al., 2002; Tarbox and Pogue-Geile, 2008). This is even more important given the fact that no associations were found with the usual proxies for the duration of untreated illness and chronology of the psychopathological onset. Such a lack of association is coherent with the notion of SDs as a trait-like vulnerability feature (Parnas et al., 2002; Raballo, 2009; Raballo and Parnas, 2011; Raballo et al., 2001; Sass and Parnas, 2003) rather than as a statelike prodromal manifestation, influenced by the temporal unfolding of psychopathology. Limitations An important constraint of the present study is that the results are based on a small sample. This has affected some of the analyses (e.g., we could not test the PCA on the EASE at an item level and we did not explore the sex differences within diagnostic groups). Moreover, we could not meaningfully assess interrater reliability, which would have necessarily been overestimated because of exchanges between the investigators. The data collection was indeed performed on the very first sample ever assessed with the EASE and was partly meant to refine the calibration of the instrument through extensive discussion and mutual supervision among the authors (all senior clinicians). Concretely, the EASE scores in the present sample reflect the consensual agreement among the authors and, in this respect, rather constitute a reference point (i.e., the closest approximation to a gold standard). Notably, the video-taped interviews derived from this protocol constitute the skeleton of the current training on the EASE performed yearly at the Hvidovre Psychiatric Center (Parnas et al., 2005b). Furthermore, a subsequent, interrater evaluation independently conducted on a subset (i.e., 25) of the interview transcripts revealed kappa values comparable with those obtained with the Bonn Scale for the Assessment of Basic Symptoms (Gross et al., 1987; Vollmer-Larsen et al., 2007) (i.e., about 70% of the items, that is, 39/57, had good or very good kappas). More recently, an independent Norwegian protocol confirmed the good interrater reliability properties of the EASE in a sample of first episode psychosis subjects (Moller et al. 2011). A further aspect that is worth commenting is that the study was not designed for the purpose of early detection of psychosis. This is reflected in the sociodemographic (i.e., older age) and clinical features (i.e., clinical composition with high ‘‘caseness,’’ higher severity) of the current sample. Nonetheless, the sample represents a relatively homogenous group in terms of need of care and help seeking (i.e., at referral, all of them met a severity threshold of hospital admission), although, because of the stipulated enrollment prerequisites (i.e., cooperativeness in a very comprehensive interview and informed consent), they were not displaying overwhelming degrees of psychopathology. This is confirmed by the PANSS scores, which ranged from 32 to 64 (see Table 1). On the basis of estimates of clinical severity derived from an extensive, multicentric survey (Leucht et al., 2005), all the participants could be considered ‘‘mildly ill’’ (i.e., equivalent to a Clinical Global Impression (CGI) severity score of 3, the threshold for a CGI equivalent of 4 [‘‘moderately ill’’] being a baseline PANSS of 78). CONCLUSIONS Our results suggest that the EASE is a valid and useful tool for assessing anomalous experiences of self-awareness (SDs) and provide evidence of the translational value of a phenomenologically inspired * 2012 Lippincott Williams & Wilkins Self-Disorders in Schizophrenia psychopathological approach. Indeed, the EASE is the first phenomenologically inspired tool informed by an explicit construct of SDs and specifically developed for the purpose of their clinical assessment (i.e., de facto, it provides the first gold standard for the assessment of SDs). Furthermore, we confirmed the association of SDs with relevant clinical dimensions, such as commonly used schizophrenia spectrumYspecific symptoms (i.e., positive, negative, and withdrawal) and premorbid adjustment. Hence, although time-consuming, the EASE may have much to offer in research (i.e., a potential core pathogenetic phenotype) and clinical-therapeutic settings (i.e., illuminating salient, yet currently overlooked, aspects of mental suffering in schizophrenia). Future research needs to investigate the relation between basic anomalies of self-awareness (SDs) and other, more complex modes of self-awareness (e.g., narrative identity and autobiographic selfawareness). This could also enrich our understanding of prodromal and at-risk mental states (Keshavan et al., 2011), thereby reintegrating into current clinical staging models of psychosis (McGorry, 2007; Raballo and Larøi, 2009) the core experiential features of vulnerability to schizophrenia spectrum disorders (Parnas, 2011). DISCLOSURES This research was funded by a grant from the European Union, Marie CurieYResearch Training Network ‘‘DISCOSVDisorders and Coherence of the Embodied Self’’ (035975) to A. R. 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Evanston, IL: Northwestern University Press. 582 www.jonmd.com & Volume 200, Number 7, July 2012 APPENDIX 1. Examination of Anomalous Self-experience: Domains and Item List Cognition and stream of consciousness Thought interference Loss of thought ipseity Thought pressure Thought block Silent thought echo Ruminations-obsessions Perceptualization of inner speech or thought Spatialization of experience Ambivalence Inability to discriminate modalities of intentionality Disturbance of thought initiative/intentionality Attentional disturbances Disorder of short-term memory Disturbance of time experience Discontinuous awareness of own action Discordance between expression and expressed Disturbance of expressive language function Self-awareness and presence Diminished sense of basic self Distorted first-person perspective Psychic depersonalization (self-alienation) Diminished presence Derealization Hyperreflectivity (increased reflectivity) I-split (‘‘Ich-Spaltung’’) Dissociative depersonalization Identity confusion Sense of change in relation to chronological age Sense of change in relation to gender Loss of common sense, perplexity, lack of natural evidence Anxiety Ontological anxiety Diminished transparency of consciousness Diminished initiative Hypohedonia Diminished vitality Bodily experiences Morphological change Mirror-related phenomena Somatic depersonalization (bodily estrangement) Psychophysical misfit and psychophysical split Bodily disintegration Spatialization (objectification) of bodily experiences Cenesthetic experiences Motor disturbances Mimetic experience (resonance between own movement and others’ movements) Demarcation/transitivism Domain 1 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 Domain 2 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 Domain 3 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 Domain 4 Confusion with the other 4.1 Confusion with one’s own specular image 4.2 Threatening bodily contact and feelings of fusion with another 4.3 * 2012 Lippincott Williams & Wilkins Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. The Journal of Nervous and Mental Disease & Volume 200, Number 7, July 2012 Self-Disorders in Schizophrenia Passivity mood Other transitivistic phenomena Existential reorientation 4.4 4.5 Domain 5 Primary self-reference phenomena 5.1 Feeling of centrality 5.2 Feeling as if the subject’s experiential field is the only extant 5.3 reality ‘‘As if’’ feelings of extraordinary creative power or extraor5.4 dinary insight into hidden dimensions of reality ‘‘As if’’ feeling that the experienced world is not truly real, as if 5.5 it was only somehow apparent, illusory or deceptive Magical ideas linked to the subject’s way of experiencing 5.6 Existential or intellectual change 5.7 Solipsistic grandiosity 5.8 Extensive definitions and exemplifications for each item are provided in Parnas et al. (2005b). * 2012 Lippincott Williams & Wilkins www.jonmd.com Copyright © 2012 Lippincott Williams & Wilkins. 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