From Thoughts to Voices: Understanding the Development of Auditory ...

Rev.Phil.Psych. DOI 10.1007/s13164-015-0286-8

From Thoughts to Voices: Understanding the Development of Auditory Hallucinations in Schizophrenia Peter Handest 1 & Christoph Klimpke 2 & Andrea Raballo 3,4 & Frank Larøi 5,6

# Springer Science+Business Media Dordrecht 2015

Abstract Drawing upon core phenomenological contributions of the last decades, the present paper provides an integrated description of the development of auditory hallucinations in schizophrenia. Specifically, these contributions are (i) the transitional sequences of development of psychotic symptoms of schizophrenia as envisioned by Klosterkötter and rooted in the basic symptoms approach, (ii) Conrad’s Gestalt-analysis of developing psychosis, and (iii) Sass and Parnas’ self-disturbance approach. Klosterkötter’s contribution provides a general descriptive psychopathological approach to the transitional sequence of the development of auditory hallucinations. The key concepts in Conrad’s proposal (such as trema, apophany, anastrophy, Reflexionskrampf [hyperreflexivity] and transparence) are discussed, as their role is central as driving forces of the process from non-psychotic symptoms to overt hallucinations. Finally, Parnas and Sass link psychiatry to philosophy and psychology, and provide an in-depth and thorough description of these phenomena in their work on schizophrenia as a disorder of consciousness and self-experience (disturbed ipseity) with hyper-reflexivity and diminished self-affection as key aspects.

* Peter Handest [email protected] 1

Mental Health Center Nordsjaelland, Dyrehavevej 48, 3400 Hilleroed, Denmark

2

Mental Health Center Ballerup, Maglevaenget 2, 2750 Ballerup, Denmark

3

NORMENT, KG Jebsen Centre for Psychosis Research, Division of Mental Health and Addiction, University of Oslo and Diakonhjemmet Hospital, Oslo, Norway

4

Department of Mental Health, Reggio Emilia, Italy

5

Department of Psychology: Cogniton and Behaviour, University of Liège, Liège, Belgium

6

Department of Biological and Medical Psychology, University of Bergen, Bergen, Norway

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1 Introduction E. Kraepelin - Dementia Praecox and Paraphrenia (1919). For the most part the origin of the voices is sought for in the external world … At other times they do not appear to the patients as sense perceptions at all. There is an Binner feeling in the soul^, an Binward voice in the thoughts^; Bit is thought inwardly in me^; it Bsounded as if thought^; Bit was between hearing and foreboding^. (p.8) E. Bleuler - Dementia Praecox or the Group of Schizophrenias (1952). Although auditory hallucinations are a matter of great preoccupation, even intelligent patients are not always sure that they are actually hearing the voices or whether they are only compelled to think them. There are Bsuch vivid thoughts^ which are called Bvoices^ by the patients. At other times they are Baudible thoughts^ or Bsoundless voices^.^ (p. 110) Auditory hallucinations are common in schizophrenia and other psychotic conditions. As observed by Jaspers (1913), such psychopathological phenomena are irreducibly linked to an impression of reality grounded in perception. In schizophrenia, this is reflected in an overall transformation of subjectivity with a radical change in the stream of experience, involving the perceptualization of thought. Such emerging qualitative changes in the content of consciousness were already described by Bleuer (1952), who observed that some patients Bare not always sure that they are actually hearing the voices or whether they are only compelled to think them^. There are such Bvivid thoughts, which are called voices by the patients^. This descriptive richness is vastly impoverished in mainstream definitions of auditory hallucinations adopted in most of contemporary (neo-kraepelinian and post-DSMIIIR) research, by de facto equating them to mere disorders of acoustic perceptions. Furthermore, such an approach neglects important, phenomenological features of the psycho-pathogenesis of auditory hallucinations. This is particularly evident in the prodromal phases of schizophrenia, where non-psychotic experiential precursors develop into psychotic phenomena such as auditory hallucinations through a series of progressive experiential changes. Therefore, familiarizing clinicians and researchers with these anomalous experiential changes in the development of auditory hallucinations is important for at least three reasons. Firstly, in order to facilitate the early recognition of impending psychosis; secondly, to provide an understanding of schizophrenic symptoms in view of psychoeducational and therapeutic support, and thirdly, to orient research in the etiology of psychosis and thus providing suitable early phenotypic markers of psychosis. The aim of this paper is to delineate a phenomenologically inspired model of the development of auditory hallucinations in schizophrenia that could serve both as a clinical guide (for psychopathological exploration) and as a heuristic framework to characterize some of the symptom generation pathways that lead to full-blown psychosis. Specifically, we strive to provide a clinically grounded phenomenological account of the pathogenesis of auditory hallucinations by building on core, selected phenomenological contributions. These contributions are: (i) the post-Jasperian notion of basic symptoms and the transitional sequences leading to first rank symptoms, (ii) Conrad’s Gestalt-analysis of the development of psychosis, and (iii) recent phenomenological research on disorders of subjectivity in schizophrenia. Most importantly, we wish to remain faithful to the clinical richness of auditory hallucinations as captured during more than one century of clinical

From Thoughts to Voices: Understanding the Development

psychopathologic research on schizophrenia, and epitomized in the quotes from its founding fathers, Kraepelin and Bleuler (see the quotes above). There are at least two ways of understanding the term phenomenological psychopathology. One is the descriptive phenomenology that tries to give rich, detailed, careful and qualitative descriptions of the various symptoms and signs of psychiatric disorders. It is the basis of psychopathological instruments used to classify and diagnose, such as the Present State Examination. Another is a psychopathology inspired by phenomenological philosophy that describes the basic structures of human consciousness and subjectivity, and the deviations of these structures, with emphasis on the understanding of the subjective experiences of the individual. This is sometimes referred to as Bthe continental phenomenological psychiatric tradition^. 1.1 The Psychopathological Pathway to Schizophrenic Hallucinations The development of schizophrenic psychosis as a breakdown of the Self (i.e., a transformation of subjectivity in its structural features) was proposed already at the turn of the 19th and 20th centuries by several leading psychiatrists such as Bleuler, Jaspers, Gruhle, Berze, Schneider, Conrad, Minkowski, Binswanger, Ey, Tatossian, Blankenburg and Laing (see Parnas and Sass 2002 for a review). This breakdown of the Self and the related development of psychotic psychopathology, including schizophrenic hallucinations, has been described in various terms by those authors. Yet, in all descriptions, a common characteristic is the qualitative change in the medium of consciousness that accompanies the transition towards psychotic phenomena. We will specifically describe the contributions of the basic symptom model, developed by Huber, Gross and Klosterkötter in the context of the post-Schneiderian tradition in psychopathology, and Conrad’s multiphase model of the onset of schizophrenia. Both of these approaches try to bridge the gap between the diagnostically relevant changes in experience (i.e., the phenomenological level of symptoms) and biologically oriented etiological research (i.e., the presumed neurobiological substrate level). Huber, Gross and Klosterkötter’s model is closer to a descriptive phenomenology, whereas Conrad’s Banthropological analysis^ tends to have a more philosophical phenomenological slant. Thus, the combination of these two major contributions can be extremely illuminative in the context of an understanding of the phenomenological development of auditory hallucinations. Huber, Gross and Klosterkötter’s model is based on extensive long-term exploration and interviewing of a large cohort of patients with schizophrenia. This eventually underwent sequential refinements that lead to the development of specific assessment tools (described later in the paper), as well as to the description of specific criteria to stratify the risk of impending psychosis (Klosterkötter et al. 2001; Schultze-Lutter 2009; Schultze-Lutter et al. 2010). This model provides a structural map of the transitional sequences leading from non-psychotic anomalies of subjective experience (basic symptoms) to Schneiderian first rank symptoms (i.e., overt delusions and auditory hallucinations). Basic symptoms are described in the Bonn Scale for the Assessment of Basic Symptoms (BSABS) (Gross et al. 1987, 2008). Conrad’s account emphasizes discrete qualitative stages that dynamically shape such transitions. Conrad developed his stage model of impending schizophrenia on the basis of in-depth interviews and minute descriptions of a large and uniform sample (n=107)

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of World War II soldiers whom were referred to him in 1941/42 while he was serving as a psychiatrist in the German army. Sass and Parnas (2003) have more recently proposed an account of the experiential genesis of auditory hallucinations that enriches and complements the insight in both the basic symptom model and Conrad’s account. In particular, Sass and Parnas (2003) situated previous clinical-descriptive accounts within the framework of Husserlian philosophy, focusing on structural alterations of self-consciousness as the basis for the development of psychotic symptoms. They argue that auditory hallucinations (as well as other psychotic symptoms) arise from progressive experiential changes that include the spatialization of experience, perceptualization of the stream of consciousness, and objectification of inner speech. All these phenomena reflect a fundamental disturbance of the basic self (i.e., the primordial, pre-reflective sense of existing as a unified, embodied subject of experience). Parnas et al. (2005) have published the Examination of Anomalous Experience scale (EASE), a thorough and comprehensive description of subjective disturbances within the schizophrenic spectrum, which gives an excellent overview of these phenomena and provides a starting point for systematic research study and for clinical work. Parnas and Sass’ approach is concerned with the earliest experiential precursors, while Conrad emphasizes the late prodromal phase, the development of psychosis and the subsequent psychotic symptoms. Finally, Huber, Gross and Klosterkötter’s basic symptoms approach gives a well-founded analysis of their sequential transitions. Brought together, these approaches give (1) a description of the development of typical psychotic symptoms in schizophrenia from the earliest experiential precursors, (2) precise descriptions and definitions of these phenomena, (3) scales for their assessment (BSABS, EASE), (4) an understanding of these phenomena from a phenomenological viewpoint with (5) links to philosophy and psychology of past and present. 1.2 Huber, Gross and Klosterkötter’s Basic Symptoms: Transitional Sequences to Auditory Hallucinations Basic symptoms are subtle, subjectively experienced subclinical disturbances in drive, affect, thinking, speech, perception, bodily sensations, motor action, central vegetative functions, and stress tolerance. They are clearly distinguished from psychotic experiences and are conceived of as the closest phenomenological correlates to the underlying neurobiological disturbances manifested in schizophrenia (Gross et al. 1987, 2008). Regular transitions from basic symptoms to the typical manifestations of schizophrenic psychoses are described in terms of Btransitional sequences^ (Klosterkötter 1992). They are defined as linear, phenomenologically coherent connections from elementary basic symptoms to Schneiderian first rank symptoms of psychosis. These transitional sequential patterns involve the following stepwise progression: 1) Basic irritation phase (initial disturbances): unspecific subjective disturbances of perception, thinking, speech, memory, actions and body sensations. 2) Psychotic externalization phase (intermediate phenomena): non-psychotic symptoms more typical (specific) of schizophrenia such as derealisation, depersonalization, delusional mood, thought blocking, pressured thinking, disturbed discrimination between thoughts and perceptions, etc., and Bas if^ experiences e.g., of body and will being influenced. The Bas if^ term corresponds to the patient who


often uses this expression to convey to the interviewer that he knows that these experiences are abnormal. The patient does not believe that that he is being influenced (delusion), but describes the experience as just like it. 3) Psychotic concretization phase (final phenomena): the specific, Bas if^ phenomena have developed into hallucinations and concrete delusions of influence, thought withdrawal, broadcasting, etc. Highly relevant in respect to this paper is Klosterkötter’s (1992) description of the transitional sequences, which showed that the majority of patients with schizophrenia, who later developed auditory hallucinations, reported self-perceived, non-psychotic changes in the prodromal phase that correspond to specific cognitive basic symptoms, including thought interference, thought perseveration and pressured thinking. According to the transitional sequences, the development of hallucinations (Fig. 1) starts with unspecific cognitive subjective disturbances of memory, thinking and concentration. This starts by first turning into thought interference, pressured thinking and obsessive-like perseveration of mental content, which then intensify into higherorder phenomena such as audible thoughts, and disturbed discrimination between thoughts and auditory images. Thereafter, audible thoughts and disturbed discrimination of auditory images and actual acoustic perception become more and more prominent. Finally, commenting and discussing voices emerge. This, and the other sequences, offers a precise description of the symptomatological progression (mostly on a descriptive level) that can be enriched by resorting to Conrad’s gestalt-analysis of impending schizophrenia. Indeed, Conrad’s concept cluster of apophany, Reflexionskrampf (hyperreflexivity) and transparence can further illuminate the experiential change that drives this process. 1.3 Conrad’s Phase Model of Impending Schizophrenia Conrad’s model (Conrad 1958) depicts four developmental stages related to the formation of psychotic symptoms: trema (i.e., the initial phase), apophany (i.e., the phase in which an incipient delusion becomes Bvisible and apparent^, with the quality Imperative, commenting and conversing voices

Final phenomena

Audible thoughts, disturbed discrimination between auditive images and perceptions Intermediate phenomena

Thought interference, pressured thinking, thought block, obsessive-like perseveration

Disturbance of memory, concentration and other subjective cognitive disturbances

Initial disturbances

Fig. 1 The development of auditory hallucinations, modified after Klosterkötter (1992)

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of a revelatory experience), apocalypse (i.e., the true eruptive phase) and, finally, the consolidation phase. During these phases, the individual suffers from an immediate and profound worry due to his inability to surmount the autocentric (Ptolemaic) frame of experience (which Conrad describes as being ‘trapped’ in a reflective mode). In the writings of Conrad and Huber, Gross and Klosterkötter (and other European continental psychiatrists), there is often a reference to the Ptolemaic versus the Copernican view of the world in schizophrenia. Therefore, a short description of this way of describing a crucial element in the development of schizophrenic psychosis is provided. The Ptolemaic view is that the sun and planet orbit around the Earth. This is equivalent to the patient view in psychosis. Reality, or the Copernican view, is that the earth (and the other planets) orbit around the sun. This is the view of others. In the development of psychosis, the patient loses the ability to take the Copernican view on himself. He loses the ability to look at himself with the eyes of another person and thereby loses the ability see his symptoms as symptoms, but instead experiences them as reality. In this process - i.e., the subjective dynamic oscillation between allocentric (Copernican) and autocentric (Ptolemaic) viewpoints - the phenomena in the field of experience change significantly, into a mode that is strictly self-referential. The ability to shift between the two ontological standpoints is lost in the schizophrenic psychosis. Conrad called loss of BÜberstiegsfähigkeit^ or loss of the ability to evaluate one’s own experience correctly when in contradiction with agreed laws and rules of the world. A typical example is the patient with schizophrenia who is convinced that others share his thoughts. 1.3.1 Trema The prodromal phase, the trema, is characterized by a certain experiential atmosphere. Trema (stage fright or BLampenfieber^, literally Blamp-fever^) is a term that Conrad borrowed from the world of theatre and that refers to the specific kind of excitement or tension before a performance. Lamp-fever addresses two aspects of this experience: the feverish, anticipatory excitement, and the sense of being exposed in the spotlight. A person during a prodromal phase often has an overwhelming feeling (bordering on certainty) that something important is going to happen and often feels over-exposed to such an impending transformation. The trema is often, but not necessarily, characterized by such symptoms as fear and a feeling of detachment from other people. The characteristic aspect of the trema is a restriction or narrowing of the entire field of existence, which can only be resolved by passing through the Bsituation^, that is the performance on stage. Passing through the Bsituation^ refers to the fact that the trema has developed into psychosis, that the individual has found a Bsolution^ to the experienced tension. In the context of auditory hallucinations, this could involve going from the annoying experience of experiencing thought interference, pressured thinking, audible thoughts etc., to (more or less suddenly) having the knowledge that voices are talking to you. Such psychotic actualization would contribute to a significant decrease in the individual’s level of anxiety and thereby decreasing tension. As trema resolves, delusional ideation unfolds and marks a transformation of the entire experiential structure, covering all modes of intentionality from perception, imagination, and thinking – which Conrad saw as the cornerstone of the early phases of schizophrenia. This transformation is characterized by the concept-cluster of apophany, anastrophy and transparence.


1.3.2 Apophany of Outer and Inner Space (World) Apophany of outer and inner space comes from the Greek Bapo^ [away from] and Bphaenein^ [to show]. It refers to the experience of seeing meaningful patterns or connections within random or meaningless data. It is a state of arousal, where the original agreed upon meaning of signs and symbols of the world change, subjectively akin to a revelatory experience (i.e., private, unescapable and self-evident). Conrad coined the term in order to refine, expand upon, and make more practical the German concepts of Babnormes Bedeutungsbewusstsein^ (abnormal awareness of meaning) and BBeziehungssetzung ohne Anlass^ (making connections without a cause – delusions of reference). Apophany thus bears a certain semantic resemblance to the terms Brevelation^ and Bepiphany^. Conrad characterized the apophanous mode of experience like this: BThe afflicted behaves like the man in the Revelations^. The meaning of events is evident and characterized by a total absence of doubt for the afflicted and, furthermore, other persons’ doubts are met with disbelief (loss of Überstiegfähigkeit). These experiences can be of a delusional degree (delusional perception, i.e., a normal sensory perception, to which a person attributes a delusional meaning) or may involve more subtle, non-psychotic changes in the perception and experiencing of the inner and outer world. There are three stages of apophany: 1. Pure apophany: The experienced object ineffably Breveals^ itself as having a particular meaning for the person, who is still uncertain about what that particular meaning might be. Case example (from authors). An excerpt from an inpatient diagnosed with schizotypal disorder, ICD-10 (schizotypal personality disorder, DSM-5) describing his changed experience of the surrounding world prior to his hospitalization: … and then being in the subway, I was able to calm down a little bit. However, after a short while the billboards - you know, they have these advertising billboards hanging on the walls - the text on the billboards began to speak in an important way to me. Well, I cannot remember what it was, but the text on the billboards were like aimed at me. That is, they had this deeper meaning - a deeper meaning specifically to me. 2. Feeling of stagedness: The experienced object Breveals^ itself as having a particular meaning for the afflicted, and the afflicted immediately knows the meaning (e.g., the object having been placed there to test him). Conrad gives us this example: BA patient is asked to choose the most beautiful postcard among 16 different postcards, but declines the task. It is impossible in his current state of mind, which he maintains despite numerous and extensive invitations. Nor reframing it, i.e., that he is in a bookstore and has to find a postcard for a friend, can persuade him. When asked why not, he answers that it would be quite hopeless, that he would not be able to describe it. The patient became more and more confused by this request. He apparently has the feeling of being in an extremely important test situation, as if his life depended on the card selection.^

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3. Delusions of reference: The experienced object Breveals^ itself as having an exceptional and specific meaning for the afflicted. The main case (Rainer) described in Conrad (1958) has the persecutory delusion that his superiors constantly follow everything he is doing to test him to find out whether or not he is suited for becoming an officer. In his narrative, there are several examples of objects, situations, etc. revealing an exceptional and specific meaning just for the patient. For instance that Bthe bed creaking^ at night in the occupancy room meant that his fellow soldiers were Bsneaking up on him^. A group of soldiers handling their rifles meant Bpull yourself together!^ A damaged car engine meant that things would go wrong. A big BN^ on a railway sign meant that his wish to become an officer would not be fulfilled. A Bgreen truck tarpaulin^ meant Bnew hope^. Animals roaring meant that he was going to be slaughtered like an animal. Drops of water on cheese lying on a table meant that he once and for all should get his act together, and so on.

1.3.3 Anastrophy During the anastrophy stage, the person experiences himself as the passive centre of the world. BI have a feeling that everything revolves around me.^ The passive element is of special importance. Conrad describes this as Reflexionskrampf – equivalent to hyperreflexivity as defined by Parnas et al. (2005), or a state of affliction where the delusional person becomes a prisoner of his own ego. While reflection is normally conceived of as a voluntary operation of the mind, or a Bliberation from the unconscious darkness of unreflecting (animal) life^, the afflicted is trapped in this operation, making the possibility of surmounting it impossible. The Bstepping over^ (BÜberstieg^) into a frame of reference other than the reflexive one is not possible, and thus effectively suppressing the conduct of everyday life. Case example (from authors). Sasha diagnosed with schizotypal personality disorder, describing hyperreflexivity: I wasn’t able to listen to the radio because I was thinking that what I heard was just sound waves going into my ears, forming a certain frequency that made me hear something. That it actually was just an illusion. And that’s what sound is, isn’t it! The same thing may well occur when I watch television. That I then think way too much about it. While apophany describes the changes of the world and its objects in relation to the subject, anastrophy denounces the way that the BI^ appears to itself – that is, as the centre of the world. The interdependence of the two (apophany and anastrophy) is crucial to Conrad, thus: Bwhenever there is an apophanous experience, the I has to undergo an anastrophic change^. That is, when in the apophanous mode, the person inevitably also experiences (suffers from) hyperreflexivity. According to Conrad, hyperreflexivity has an immediate influence on the way mental content is experienced. This can be experienced even in an everyday-like way. When intensively focusing on a certain word or concept and thinking of all its meanings, and/or repeating the word or


concept in your head, it can be experienced that the word or concept looses its significance and meaning. Some case examples (from authors) of changed experience due to hyperreflexivity: Female patient diagnosed with paranoid schizophrenia describing an inner feeling of restlessness: What is restless? It is a combination of rest and less. What is rest and what is less? How are they connected? Rest, rest, rest, less, less, less, restless, restless, restless. Those words continue to go on in my head. Rest means certain differing things and less likewise. What is actually the meaning of restless? Here, the patient is Ba prisoner of her own reflection^ and her knowledge of restless is disappearing. In her apophanous state of Babnormal awareness of meaning^, the normal meaning of being restless disappears leading to an alienation from linguistic common sense. Case example (from authors). Sasha, (same Sasha as above) describing a changed way of experiencing herself due to hyperreflexivity: It’s that thing, all the time feeling outside yourself; like you can hear yourself talking - that you can see yourself doing things. I have had a very unpleasant experience, as if I was looking out through my own eyes, because I was aware of myself looking. I experienced that I was placed somewhat behind myself. That I wasn’t actually a part of my movements, my voice, my eyes. I was kind of retracted. As if, I have a kind of superior consciousness that I did not have before. Then I was embedded directly in myself, now I’m so out of myself. Asked to clarify the meaning of Bsuperior consciousness^, the patient answered: It is that I reflect upon myself, my own impressions, on myself. Whereas a dog, a Labrador retriever, would just be in its own self, and would never think upon itself. It would instinctly do just what it wanted to do. I think of all the things I do, because I observe myself from the outside. The patient describes an experience of alienation toward herself. Even looking at the world is experienced as something she does from a distance. In this way, hyperreflexivity changes the way the patient experiences herself and the world. The way the patient describes her fundamental problem resembles the patient Anne from Blankenburg’s (1971) BDer Verlust der natürlichen Selbstverständlichkeit^, where the patient is trying to describe what this loss of common sense is: I don’t know – how shall I put it – I’m so low-spirited and crouched. I can never really be part of things and participate. I don’t know - it is always the same really. I don’t know what to call it. I just call it… It is just… I don’t know, no knowledge, it is like… Every child knows this! The similarity of metaphors is striking. Anne experienced lacking something that even a child possessed, our patient was lacking in something even a dog has. Both a

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child and a dog are commonly perceived of as behaving straight forward, spontaneously and instinctively, and without excessive thinking prior to actions. 1.3.4 Transparence Apophany and hyperreflexivity entail a mode of experience that influences the content of consciousness (of the inner and outer world/space). To begin with, apophany often spares the inner space, while the outer world starts to be experienced in an apophanic light. This leads to what Conrad calls Bdedifferentiation^ (Entdifferenzierung), where certain characteristics (Wesenseigenschaften) of the outer world gain primacy over the whole. As things progress, however, the Blocalization^ of experience changes: BThe inner and outer world begin to communicate^, and the inner space becomes progressively transparent. As a consequence of the apophanous mode of experience and hyperreflexivity, the person experiences a distance to contents of his own consciousness, e.g., thoughts. Initially, the person describes an experience of strangeness towards his own thoughts (auto-psychic depersonalization), further on, the experiential distance is accentuated, and a quality of alienation of thoughts emerges, and in the end, there is a complete lack of ownership of thoughts. Thoughts may thus first be identified as one’s own, then as Bafflatus^ (i.e., the staggering and stunning blow that ensues at the appearance of a new idea, an idea that the person may not be able to explain) where there is a primacy of the ‘outer’ and where thoughts may be experienced as inserted or even forced upon the subject, and finally take the form of commanding or threatening voices. This can be seen in the form of symptoms such as thought insertion, thought broadcast, audible thoughts and auditory hallucinations. Case 61 (from Conrad) constantly complains about the reading of his thoughts. Even when he writes and reads, what he reads is simultaneously read aloud by someone else. He received a text to read. After looking at it for a moment, he looks up and says: BDid you hear that?^ Case 11 (from Conrad) comments: BAs soon as I think about something, somebody else says the thoughts out loud. About 8–10 people can do that.^ […] BWhen I wrote a letter, he (another patient) prompted every word. I heard every sentence beforehand.^ […] BEverything I read is repeated, I hear it exactly, it gets repeated outside on the porch.^ Case 60 (from Conrad) reports that he has been hearing commenting voices for a number of years. When he was about to eat or light a cigarette, he heard: BNow he is about to eat^ or Bnow he is going to light a cigarette^. These remarks were always made in another room than the one the patient was in. According to Conrad: BPhenomenologically, the differences between the experience of thought-broadcast and audible thoughts are merely differences of degree^, even though these symptoms are normally categorized in two different diagnostic domains – as thought disorders (Denkstörungen) and perceptual disorders (Wahrnehmungsstörungen), respectively. Conrad contests this view and argues that these hallucinations genetically and directly originate and develop in thinking, and thus represent a higher degree of transparence and communication between ‘inner’ and ‘outer’ space. From this perspective, (commenting) voices are another expression of hyperreflexivity where everyday life is subjected to a constant monitoring by the ego. The myriad manifestations of these phenomena are, according to Conrad, dependent


upon the patients’ pre-morbid differences in styles of thinking and internal dialogue. People may, for example, address themselves in the first or second person while others employ different forms of word play. 1.4 The Development of Auditory Hallucinations: Combining the Concepts of Klosterkötter and Conrad The development of auditory hallucinations from the view of Klosterkötter (1992) starts with unspecific disturbances of memory and concentration, the basic irritation phase (Fig. 1). Our main case, Erik, describes the symptoms in the following way: Case example (from authors). Erik describing unspecific subjective, cognitive disturbances. …I was unable to do anything. I found it hard to attend to my studies. It was difficult to concentrate when reading my books, and difficult to understand what I read, and remember what I read. I was pretty desperate, because there were all these exams I had to pass. During this time, I was lying on the bed and looked up at the ceiling, and smoked cigarettes, and drank coffee and did not think of anything. In this stage, the patient is already in the experiential state of apophany and hyperreflexivity, which changes the way the patient experiences himself and the world as described above. Due to the Baction^ of hyperreflexivity and apophany, a loss of control of his own thoughts appears and the unspecific cognitive disturbances are transformed into pressured thinking, thought interference, and obsessive-like perseveration of mental content (Fig. 2). Pressured thinking refers to having the impression that many thoughts (or images) with different, unrelated or remotely related meaning/content pop-up and disappear in quick sequences without the patient being able to suppress or Imperative, commenting and conversing voices

Apophany

Hyperreflexivity

Final phenomena

Transparence

Audible thoughts, disturbed discrimination between auditive images and perceptions

Hyperreflexivity

Transparence

Intermediate phenomena

Thought interference, pressured thinking, thought block, obsessive-like perseveration

Hyperreflexivity Disturbance of memory, concentration and other subjective cognitive disturbances

Initial disturbances

Fig. 2 The development of auditory hallucinations: the interaction of the Klosterkötter (1992) and Conrad (1958) concepts

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control the appearance and disappearance of contents of consciousness. Thought interference is the sudden appearance of thoughts without the patient having the intention of initiating these thoughts. Obsessive-like perseveration is ruminating on all kinds of things from urgent matters to insignificant trivialities, which is differentiated from pressured thinking, as thoughts are not chaotic, but sequential. The patient has entered the intermediary phase. Case example (from authors). Erik describing pressured thinking: I’m very familiar with the experience of thinking or trying to think many thoughts at the same time. But they pile up, as if they were originating from many different places in the brain, so that I have no control over them - and it ends up in total chaos. Thoughts come and go with the patient being able to control the appearance and disappearance of thoughts. As the contents lack a common theme and are at times irrelevant to the patient, this enhances the feeling of loss of control. The patient experiences a change in both content and form of thoughts, which causes a loss of coherence or meaning for the patient. The lack of control, coherence and meaning amplifies the effect of the driving forces - apophany and hyperreflexivity. Patients often use variations of Bdistance^ or Bnot genuine^ to describe the changed experiences of thoughts (and the world). This amplifies the generators of auditory hallucinations, i.e., apophany and hyperreflexivity that push thoughts into the next phase. During this transformation, transparence also starts functioning as a generator. The experiencing of mental content as distant and/or not quite genuine contributes to the formation of transparence, which in turn further changes the way mental content is experienced. In the next stage, the patient experiences perceptualization of thought (Gedankenlautwerden), that is, thoughts that become audible to him, but not to others, and the development of transparence is clearly visible as the patient becomes uncertain as to the place of origin of his own thoughts, ideas, etc. Case example (from authors). Erik describing audible thoughts: I often hear my thoughts inside my head, and at the same time, I see them written down. It is as if I read aloud from a piece of paper, on which my thoughts have been written down. The patient also experiences visible thoughts. Which is another example of change in the form of thoughts. In the authors’ experience, these two experiences – audible and visible thought, are often reported as occurring together. Case example (from authors). Erik describing disturbed discrimination of audible images and perceptions: It has been a recurring thing, that I heard phones ringing, or that the phone rang, and I hear it in my head, and I know perfectly well that the phone is not ringing. But it keeps ringing inside my head anyway. And every time I feel a jerk in me and I’m almost starting to get up, and go


and pick up the phone. So sometimes I don’t know if the phone is ringing or if I am imagining it. The development of intermediary phenomena into actual voices highly depends on transparence created by the mode of apophanous experience and hyperreflexivity. As the process of apophany, hyperreflexivity, transparence and alienation of mental content continues, the mental content is experienced as more distant and possessing a clear quality of strangeness or a sentiment of Bnot really mine^. Along with this process, perceptualization of thoughts also increases. Finally, the patient experiences thoughts as alien, Bdefinitely not mine^ and so distant that they are perceived as either internal voices or, if the transparence has gone even further, as external voices. Case example (from authors). Erik describing his voices: I’ve had experiences, where at the same time I saw cobblestones, darkness, and a dark street and heard rain in front of me. I was able to recognize this as the place I lived at the time. It was as if I was standing on the fourth floor and looking into the rain and down on the dark street, the cobblestones and at the street lamps, and there was something with that window up on the fourth floor, which was very appealing to me, and very dangerous. I heard the rain and voices from the window, which both encouraged and ordered me to get over to the window and jump out to commit suicide. It lasted about 5–10 min and while I was watching and hearing it, it was actually real, but afterwards I knew very well that it was a hallucination of some kind.

1.5 Parnas and Sass’ Basic Disorder of Subjectivity and Auditory Hallucinations in Schizophrenia (Parnas and Sass 2002; Parnas et al. 2012; Parnas et al. 2011) approach builds on both previous clinical-psychopathological insights into the experiential level of the development of psychotic experiences, and philosophical-phenomenological descriptions of the structure of human consciousness. Their approach offers a strong linkage to philosophy and psychology and an expansion of the description of schizophrenic psychopathology based on concepts from these two fields. The link to phenomenological philosophy and psychology is stronger or at least more explicitly formulated than with Conrad and Huber, Gross and Klosterklötter. Parnas and Sass’ approach provides a further description and understanding of the phenomena described above (and of other phenomena important for the understanding of schizophrenia). Parnas and Sass’ ipseity-hyperreflexivity model claims that instability of prereflective self-awareness is a core, generative feature of schizophrenia that affects the minimal or core self (Parnas and Sass 2002; Parnas et al. 2012). Ipseity (Latin for self or it-self) refers to an experiential sense of being a vital, self-coinciding embodied subject of experience endowed with a unique first personal access to the world. In nontechnical language, that I know without thinking that I am me, myself, and every gesture, action, utterance, feeling, emotion, etc. is mine or me. In that this experience is so self-evident to me, I never think about it. Only when forced to do it, however, will I become aware that this is actually a unique experience.

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The two main features of the ipseity disturbance are hyperreflexivity and diminished self-affection. According to Parnas et al. (2005), hyperreflexivity is a tendency to take oneself or aspects of the world as objects of intense reflection. This increase in the reflection on own thinking, feelings and behavior, causes an inability to react and behave spontaneously and in a carefree manner. Hyperreflexivity refers to forms of exaggerated automatic self-consciousness in which Bsomething normally tacit becomes focal and explicit^. This disrupts awareness and action because of the popping-up and popping-out of the normally tacit processes and phenomena. Sass and Parnas distinguish between hyperreflexivity and hyperreflectivity. The latter being a part of hyperreflexivity, but with Bfairly volitional, quasi-volitional or intellectual processes^, Ba Breflective^ kind of self-consciousness^. Hyperreflexivity has a distinct component of being outside the range of will. Clinically, hyperreflexivity emerges in phenomena such as the feeling of losing the automaticity of normally tacit, habitual sensorimotor processes animating everyday behavior (e.g., getting dressed, drinking coffee, interacting with others, etc.). Instead, the proprioceptive and kinesthetic background moves to the foreground of the patient’s focal attention. The person becomes overly aware of the effort required to produce each gesture or movement, to such an extent that his body is eventually experienced as a mechanical object, resulting in an experience of disembodiment or Bself-alienation^ (Sass and Parnas 2003, Sass et al. 2011). Actions are dislodged from the gestalt of the situational context and thus appear strange or uncanny (Wiggins and Schwartz 2007). This concept of hyperreflexivity is equivalent to the description of Reflexionskrampf by Conrad (1958). As hyperreflexivity is English and probably more understandable, the authors have chosen to use this expression instead of a translation of Reflexionskrampf into English. Diminished self-affection involves a decreased sense of existing as a vital and selfpossessed subject of awareness. The patient has a decreased sense of existing as an experiencing subject, of experiencing himself as the vital center-point of subjective life (Sass and Parnas 2003, Sass et al. 2011). In schizophrenia spectrum disorders, the subject undergoes subtle but pervasive and persistent qualitative changes of subjective experience due to the ipseity disturbance and hyperreflexivity. These include an extensive variety of non-psychotic phenomena, such as subtle feelings of alienation, depersonalization, perplexity, changes in bodily experiences, loss of the automatic attunement to intersubjectively shared meanings, as well as distortion of the primordial sense of self-presence and stream of consciousness. These anomalous subjective experiences, which are systematically described in the Examination of Anomalous Self-Experience (EASE; Parnas et al. 2005), are indicative of a disturbance affecting the very structure of experiencing, that is, ipseity. Even the perceptual act itself may rise to the level of focal awareness, e.g., BI became aware of my eye watching an object,^ (Stanghellini and Ballerini 2004, p. 113). In sum, hyperreflexivity tends to objectify normally tacit, pre-reflective processes of agency and perception, thus triggering the second, complementary component of ipseity disturbance, that is, the diminishment of self-affection. This description of objectifying and diminished self-affection resembles Conrad’s concepts of developing schizophrenia, i.e., apophany and transparence. Experiences of diminished selfaffection are, for example, the feeling of a growing inner distance from one’s own stream of consciousness (BI saw everything I did like a film-camera^ (Sass 1992)), or of


Ban inner void^ or Black of inner nucleus^ where the self would normally be (Parnas and Handest 2003a, b). The joint effect of hyperreflexivity and diminished selfaffection is a progressive and enduring erosion of the basic sense of self-presence with a contextual loss of the perspectival coherence that enables us to maintain an experiential grip on the world. This can also affect the development of auditory hallucinations that, according to Sass and Parnas (2003), might be viewed as an autochthonous transformation of inner speech (i.e., a constitutive phenomenon of our stream of thought) in the context of a diminished self-presence that no longer fills the field of consciousness. (Parnas et al. 2012) state that this phenomenology helps to understand how one form of experience leads into another, or worded differently, can inspire or motivate the transformation of subjectivity.

2 Conclusion In the introduction, we advocated three aims for this paper: to facilitate the early recognition of impending psychosis; to provide an understanding of schizophrenic symptoms in view of psycho-educational and therapeutic support, and finally to offer a foundation for research in the etiology of the pathogenetic pathways to psychosis. A phenomenologically (in both understandings of this concept) inspired approach to the experiential development of auditory hallucinations that can be used in clinical exploration is, however, still largely lacking in the contemporary scientific literature (cf. McCarthy-Jones et al. 2013; Raballo and Larøi 2011; Larøi et al. 2010). Such an approach, mapping the pathways from early, non-psychotic experiential changes to full-blown auditory hallucinations, has both clear clinical advantages and research implications. This approach captures the developmental nature of these experiences, and therefore can play a role in etiologic research, in that early prehallucinatory experiences are a closer index of vulnerability than overt symptoms of impending schizophrenia. Being aware of the psychopathological phenomena described in this paper helps both the clinician and researcher to identify patients with prodromal schizophrenia. In this respect, it is important to note that validated assessment instruments exist, such as the Bonn Scale for the Assessment of Basic Symptoms (Gross et al. 1987, 2008), the Schizophrenia Proneness Instrument (Schultze-Lutter et al. 2007) and the Examination of Anomalous Self Experience (Parnas et al. 2005). Therapeutically, having a phenomenological background provides the clinician with the insight to understand and discuss deeper issues regarding the meaning of auditory hallucinations with the person hearing them and examine how this relates to his present situation. This is of benefit for the development of cognitive behavioral techniques aimed at relieving voice-hearers’ distress, particularly with regard to being able to create meaningful formulations (McCarthy-Jones et al. 2013). Similarly, as has been previously suggested (Møller and Husby 2000; Mundt 2005; Raballo and Larøi 2011), the phenomenologically trained clinician will be uniquely qualified in accompanying the patient in the appraisal of such experiences thereby resulting in a substantial tension-relieving effect. This approach gives the patient the opportunity and space for therapeutic interaction where their subjective perception of self-alteration can undergo a narrative integration, thus empowering the patient’s sense of self-coherence.

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References Blankenburg, W. 1971. Der Verlust der natürlichen Selbstverständlichkeit: Ein Beitrag zur Psychopathologie symptomarmer Schizophrenien. Stuttgart: Ferdinand Enke Verlag. Bleuer, E. 1952. Dementia Praecox or the group of schizophrenias. Conrad, K. 1958. Die beginnende Schizophrenie. Versuch einer Gestaltanalyse des Wahns. Georg Thieme Verlag. Stuttgart, Germany. Gross, G., G. Huber, J. Klosterkötter, and M. Linz. 1987. BSABS Bonner Skala für die Beurteilung von Basissymptomen. Manual, Kommentar, Dokumentationsbogen.. Berlin: Springer. Gross, G., G. Huber, J. Klosterkötter, and M. Linz. 2008. BSABS - Bonn Scale for the Assessment of Basic Symptoms: 1st english edition: Manual, commentary, references, index, documentation sheet (Berichte aus der Medizin). Aachen: Shaker Verlag. Jaspers, K. 1913. Allgemeine Psychopathologie. Ein Leitfaden für Studierende, Ärzte und Psychologen. Berlin Springer Verlag. Translated from the German 7th edition by Hoenig J and Hamilton MW in 1959. Klosterkötter, J. 1992. The meaning of basic symptoms for the development of schizophrenic psychoses. Neurology Psychiatry and Brain Research 1: 30–41. Klosterkötter, J., M. Hellmich, E.M. Steinmeyer, and F. Schultze-Lutter. 2001. Diagnosing schizophrenia in the initial prodromal phase. Archives of General Psychiatry 58: 158–164. Larøi, F., S. de Haan, S. Jones, and A. Raballo. 2010. Auditory verbal hallucinations: Dialoguing between the cognitive sciences and phenomenology. Phenomenology and the Cognitive Sciences 9: 225–240. McCarthy-Jones, S., J. Krueger, F. Larøi, M.R. Broome, and C. Fernyhough. 2013. Stop, look and listen: The need for philosophical phenomenological perspectives on auditory verbal hallucinations. Frontiers in Human Neuroscience 7: 127. Møller, P., and R. Husby. 2000. The initial prodrome in schizophrenia: Searching for naturalistic core dimensions of experience and behavior. Schizophrenia Bulletin 26: 217–232. Mundt, C. 2005. Anomalous self-experience: A plea for phenomenology. Psychopathology 38: 231–235. Parnas, J., and P. Handest. 2003. Phenomenology of anomalous self-experience in early schizophrenia. Comprehensive Psychiatry 44: 121–134. Parnas, J., and L.A. Sass. 2002. Self, solipsism, and schizophrenic delusions. Philosophy, Psychiatry & Psychology 8: 101–120. Parnas, J., P. Møller, T. Kircher, J. Thalbitzer, L. Jansson, P. Handest, and D. Zahavi. 2005. EASE-scale (Examination of Anomalous Self-Experience). Psychopathology 38: 236–258. Parnas, J., A. Raballo, P. Handest, L. Jansson, A. Vollmer-Larsen, and D. Saebye. 2011. Self-experience in the early phases of schizophrenia: 5-year follow-up of the Copenhagen Prodromal Study. World Psychiatry 10: 200–204. Parnas, J., L.A. Sass, and D. Zahavi. 2012. Rediscovering psychopathology: The epistemology and phenomenology of the psychiatric object. Schizophrenia Bulletin 39: 270–277. Raballo, A., and F. Larøi. 2011. Murmurs of thought: Phenomenology of hallucinatory consciousness in impending psychosis. Psychosis 3: 163–166. Sass, L. A. 1992. Madness and Modernism: Insanity in light of modern art, literature, and thought, New York, Basic Books. Sass, L.A., and J. Parnas. 2003. Schizophrenia, consciousness, and self. Schizophrenia Bulletin 29: 427–444. Sass, L., J. Parnas, and D. Zahavi. 2011. Philosophy, Psychiatry, & Psychology, 1: 1–23. Schultze-Lutter, F. 2009. Subjective symptoms of schizophrenia in research and the clinic: The basic symptom concept. Schizophrenia Bulletin 35: 5–8. Schultze-Lutter, F., J. Addington, S. Ruhrmann, and J. Klosterkötter. 2007. The Schizophrenia Proneness Instrument – Adult version (SPI-A). Rome: Giovanni Fioriti Editore s.r.l. Schultze-Lutter, F., S. Ruhrmann, J. Berning, W. Maier, and J. Klosterkötter. 2010. Basic symptoms and ultrahigh risk criteria: Symptom development in the initial prodromal state. Schizophrenia Bulletin 36: 182191. Stanghellini, G., and M. Ballerini. 2004. Autism: Disembodied existence. Philosophy, Psychiatry& Psychology 11: 259–268. Wiggins, O.P., and M.A. Schwartz. 2007. Schizophrenia: a phenomenological-anthropological approach. In International perspectives in philosophy and psychiatry, Reconceiving schizophrenia, ed. M.C. Chung, K.W.M. Fulford, and G. Graham, 113–127. Oxford: Oxford University Press.