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Page 1 of 12
Schizophrenia Bulletin
https://doi.org/10.1093/schbul/sbad170
© The Author(s) 2023. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved. For
permissions, please email: journals.permissions@oup.com
Self-Disorder in Schizophrenia: A Revised View (2. Theoretical
Revision—Hyperreexivity)
LouisSass*,1,2 and JasperFeyaerts1,
1Department of Psychoanalysis and Clinical Consulting, Faculty of Psychology and Educational Sciences, Ghent University, Ghent,
Belgium; 2Department of Clinical Psychology, Graduate School of Applied and Professional Psychology, Rutgers, The State University
of New Jersey, USA
*To whom correspondence should be addressed; Department of Clinical Psychology, Graduate School of Applied and Professional
Psychology, Rutgers University, 152 Frelinghuysen Road, Piscataway, New Jersey 08854, USA; tel: 917 513-9798, fax: 732 445-4888,
e-mail: lsass@rutgers.edu
A growing body of research supports the role of self-
disorders as core phenotypic features of schizophrenia-
spectrum conditions. Self-disorders comprise various
alterations of conscious experience whose theoretical un-
derstanding continues to present a challenge. This is the
second of two articles that aim to clarify the nature of self-
disorders in schizophrenia by considering the currently most
inuential, phenomenological model of schizophrenia: the
basic-self-disturbance or ipseity-disorder model (IDM).
The previous paper (article 1) presented a state-of-the-art
overview of this model and critically assessed its descriptive
adequacy with respect to the clinical heterogeneity and var-
iability of the alterations in self- and world-awareness char-
acteristic of schizophrenia. This paper (article 2) proposes
a theoretical revision by considering how hyperreexivity
might form the crucial common thread or generating factor
that unies the heterogeneous, and sometimes even contra-
dictory features of schizophrenic self-disorders. We outline
implications of our revised model (IDMrevised) for explan-
atory research, therapeutic practice, and our general un-
derstanding of the abnormalities in question.
Key words: self-disorder/schizophrenia/basic-self-
disturbance model/hyperreexivity/ipseity-disorder
model revised
Introduction
In our rst article, we drew attention to the substan-
tial heterogeneity and variability that characterize self-
disorders in schizophrenia. We showed that alterations
of self-experience can involve not only the oft-noted di-
minished self-presence in which patients lose the sense of
being the subject or agent of their own experiences or ac-
tions, but also increased self-presence, as when patients
feel they are the sole constituting witness, central gure,
or prime target of all that occurs. We noted as well that
the eld of awareness—the lived world of objects, people,
and situations—can show up in opposite ways: either as
lacking organization, as seeming fragmented, random,
and uncertain (decreased “grip” or “hold”); but also as
hyper-organized or hyper-determined, often in a typically
grandiose/paranoid manner, such that nothing seems ac-
cidental and everything appears “just so” or as somehow
oriented toward or referring to the patient himself (in-
creased “grip” or “hold”).
These contradictory aspects may not only succeed each
other but can sometimes even co-exist. Their prominence
clearly requires revision of the current self-disturbance or
ipseity-disturbance model (IDM),1–3 which species only
diminished self-presence while also conceiving “disturbed
grip” only as diminished grip. In article 1, we suggested the
broader notions of altered self-presence and altered grip/
hold, aimed at recognizing that both these dimensions of
awareness can vary toward either diminishment or exag-
geration, and that such variation may occur across sub-
groups of patients or phases of illness, but also as more
moment-to-moment dynamic shifts and/or combinations
at the individual-patient level.
In this second article, our aim is to go beyond these more
descriptive issues by focusing on the theoretical question
of how a revised IDM-model can account for these di-
verse manifestations. According to the revised model we
will propose, it is preferable to focus on what the different
manifestations of schizophrenic self-disorders may have
in common rather than on what they purportedly lack.
More precisely, we will argue that what the diverse ex-
pressions of schizophrenic self-disorders share is not best
conceived as the absence of something that, supposedly, is
constantly present in normal or non-schizophrenic forms
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L. Sass & J. Feyaerts
of experience—namely, minimal self or self-presence. The
shared factor is better conceived as the presence of some-
thing abnormal, namely, hyperreexivity, which involves
distinct forms of alienation, detachment, inwardness,
and passivization. The self-disturbance model should be
re-congured around the concept of hyperreexivity.
We will argue for this in two main ways. In the next
section, we note difculties inherent to the concept of
minimal or basic-self as well as in its application to schiz-
ophrenic self-disorders. Here we include a brief review
of alternative proposals regarding the presumed essence
of self-disorders. In the next several sections, we explain
how hyperreexivity could serve as a central common
thread or generating factor able to unify—and in a sense,
to explain4—the phenomenologically heterogeneous, and
sometimes even contradictory, features of schizophrenic
self-disorders. In a nal section, we discuss research and
clinical implications of our proposal.
Self-Disorders as Disorders of “Minimal Self ”: A
Critical Overview
In our previous article, we noted how alterations of self-
experience in schizophrenia may take on various forms
and qualities. Beyond this heterogeneity and variability,
a more general challenge concerns how such alterations
should best be conceived—comprising questions re-
garding what kind, level, or aspect of “self” is affected in
self-disorders; in what sense it is possible for core “self-
hood” to be considered disturbed; and whether a felt sense
of self actually is a (necessary or regular) feature of ordi-
nary experience (for reviews, see5,6; for various proposals,
see6–10). Here we provide a brief overview of these debates.
A rst issue concerns the seeming contradiction be-
tween the supposedly “essential” or “universal” nature of
minimal self in human consciousness and its proposed
alteration or disturbance in schizophrenic self-disorders.
As discussed (cf. article 1), the IDM’s concept of min-
imal self refers not to some contingent quality that only
some experiences would possess, but rather, to a struc-
tural dimension of consciousness that is considered a
necessary or essential feature of how all experiences are
given to a subject—what phenomenological philoso-
pher Zahavi describes as a “rst-personal character” or
“what-it-is-like-for-me-ness.”11,12
On this conception, all human experience is intrinsi-
cally—and indeed necessarily—characterized by rst-
personal givenness and an accompanying sense of
mineness. One may wonder, however, how this suppos-
edly inalienable character of minimal self could be con-
sistent with the IDM’s account of self-disorders. How, or
in what sense, could self-disorders involve a disturbance
of minimal self if the latter is also assumed to be neces-
sarily preserved throughout subjective life, indeed to per-
sist as the necessary condition of consciousness itself?
Several responses to this problem have been offered.
One response7 consists of arguing that self-disorders do
still involve a disturbance at the level of minimal self, but
that the latter would somehow be merely “eroded” or “di-
minished” instead of being entirely absent. This solution
can seem rather ad hoc (and in fact was proposed only after
problems with the original model were noted). It would
seem, in any case, that such a dimensional or quantitative
understanding of mineness/for-me-ness runs counter to
how minimal self is actually dened and understood in the
phenomenological literature (see11,12; cf. article 1). There
the “mineness” of experience is not established by refer-
ence to feelings of greater or lesser intensity but argued for
as a logical necessity; and it is difcult to see how it could
allow of being conceived in terms of degrees. As Henriksen
et al7 point out, even for patients with severe self-disorders,
there is not (and on theoretical grounds, could not be) any
relevant doubt about who is experiencing their symptoms.
“[E]ven the pathological experiences under consideration,”
writes Zahavi,11 “retain their mineness and for-me-ness,”
their “rst-personal character.”
Another common strategy to address this problem has
been to introduce a ner phenomenological distinction re-
garding the particular kind of “mineness” that is suppos-
edly eroded or disturbed in schizophrenic self-disorders.
While various proposals exist (eg,13,14), the most promi-
nent distinguishes between the mineness of “ownership”
vs of “agency,” and interprets self-disorders as lacking
agency while preserving ownership.6
The main problem with this account is that many of our
ordinary or somewhat obsessional thoughts also come
unbidden and without a sense of agency, simply crossing
one’s mind, and may even be experienced as imposed and
intrusive, yet do not carry the sense or quality of aliena-
tion as found in self-disorders.15 There is also the fact that
schizophrenic loss-of-self can pertain not only to such ac-
tivities as thinking or moving one’s arm—which do have
an at least potentially agentic quality—but also to states
and feelings that would normally be passively enjoyed or
endured, such as emotions and sensations: What is al-
tered in these latter experiences would seem to pertain to
possession rather than to agency.
It should be noted, as well, that even the underlying
assumption—the idea that a pre-reective sense of self
necessarily imbues ordinary conscious experience—is it-
self not uncontested.16–18
Some theorists18,19 have, in fact, argued that pre-reective
experience is often and perhaps typically transparent and
impersonal, devoid of any form of self-awareness—as for
example, when we are fully immersed and unreectively
engaged in activities. Still others20 propose a more open
view regarding pre-reective consciousness, allowing for
different shades or degrees of self-awareness in diverse
situations or activities (eg, contrast the self-aware quality
of social anxiety with the mindless absorption of the
long-distance driver). Both views (whether emphasizing
the supposed transparency or the supposed heterogeneity
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Self-Disorder in Schizophrenia: Revised View (2)
of normal self-experience) would seem inconsistent with
the notion that schizophrenic self-disorders involve loss
of some form of self-awareness presumed to be ubiqui-
tous in non-schizophrenic forms of consciousness.
Hyperreexivity as the Central Factor
We see, then, that there are problems with the notion of
diminished minimal self as currently formulated. Though
clearly an important symptom, it is not a constant one
nor can it serve as a dening feature of schizophrenia.
This is due not only to the importance of antithetical
forms of exaggerated self-presence or “for-me-ness” (cf.
article 1), but also (as just noted) to conceptual difcul-
ties inherent in adapting a supposedly universal or tran-
scendental notion to capture empirical variations on the
psychological plane.
One may speak of alterations or anomalies of self-
presence as key factors, but only so long as one recognizes
that these disturbances can deviate in opposite, and per-
haps paradoxical, directions (ie, not always or only toward
diminishment). Philosophers discuss whether a truly thin
notion of “core self” or minimal self-presence should be
considered a sine-qua-non either of subjectivity or phe-
nomenal consciousness itself, or of normal or ordinary
consciousness.7,11,16–22 Here we take no position on these
vexed questions. Our focus is on comparative and empir-
ical issues concerning variations of felt self-presence that
might be discernable across diverse psychiatric conditions
or between distinct kinds of human experience. For us,
the key opposition would not be between a (presumably
normal and constant) presence of self-presence versus its
(supposed) absence or diminishment in schizophrenia,
but rather: between more normal forms of pre-reective
immersion and absorption, however, these be understood
(that is: whether as involving minimal self or not), versus
hyperreexive experiences involving altered self-presence.
The considerable heterogeneity of schizophrenic symp-
toms (together with their waxing and waning over time)
has long been recognized, and currently fuels skepticism
about the validity of “schizophrenia” as a disease entity
or distinct syndrome.23 Our own emphasis on opposite
and even paradoxical aspects could contribute to such
doubts. “Schizophrenia” does, however, have a long his-
tory, and there are reasons to consider it a valid and nec-
essary category.24 Like nearly all psychiatric diagnoses,
schizophrenia is unlikely to be a true “disease entity,”
with a unifying or singular cause and course; rather it is
a syndrome comprising a diverse set of co-occurring fea-
tures. But this does not mean we must forego all further
explanation, limiting ourselves to listing co-occurring
symptoms and signs. We agree with Karl Jaspers’ view of
schizophrenia as a particularly mysterious yet indispen-
sable category, and as one in which alterations of self-
experience have a central importance (Jaspers spoke of
abnormalities of the “Cogito”).25
The IDM is one attempt to clarify and account for
the unity of this condition; it describes a number of
aspects that are intimately inter-related in various ways.
We will now suggest that a component of the IDM—
hyperreexivity—may be the best candidate for bringing
the disparate features of the syndrome together by
showing their mutual implications and understandable
interactions. Hyperreexivity can be understood as what
Eugene Minkowski26 termed a trouble générateur: namely,
a shared or unifying theme that permeates all the major
symptoms as well as an originating process, an orienta-
tion or existential mode that contributes to development
of these same symptoms: see gure 1B.
Hyperreexivity’s congruence with both diminishment
and increase of both self-presence and grip—and with
the paradox of their co-occurrence—offers a way of
understanding what can otherwise seem the strange or
even inconceivable experiences that can occur. We shall
argue that such an approach is congruent as well with
the agentic ambiguities of schizophrenia,27 ie, with its
distinctive combination of quasi-intentional with pas-
sively endured factors (of “act and afiction”28), and
with the temporal variability of symptoms29,30 that this
combination may help to explain. As we shall see, such
an approach locates the essence of schizophrenia not as
diminishment or loss but as a heightening of the para-
doxical heart of human subjectivity itself: the potential
for reexive self-awareness and self-distancing.
Hyperreexivity: Denition and Historical Antecedents
Hyperreexivity Dened
Hyperreexivity can be dened as a rendering-explicit
of aspects of experience that are normally transparent
or implicit, as a bringing-to-the-fore what might other-
wise have remained in the background of experience. It
obviously implies a kind of inward-turning but also an
extrusion, an alienation of that which is taken as the
object of attention.28,31 Like most words applied to con-
sciousness or subjective life, “reexive” is ambiguous.
Here it will refer to a condition in which something is
directed or turned back upon itself, and this should
be understood in an inclusive sense. The “reexivity”
in “hyperreexivity” refers not only to volitional, in-
tellectual, metacognitive, or reective forms of self-
consciousness (these might be termed hyper-reective
hyperreexivity), but also to a more passive undergoing
or “suffering” of more spontaneous anomalies of con-
sciousness and attentional or perceptual focus (termed
“operative hyperreexivity”)—as when a patient nds
herself noticing, say, kinesthetic or proprioceptive
sensations in her elbow or eye sockets, or somehow
“hearing” the inner speech that would normally serve as
the unnoticed medium of her thinking. The operative-
vs-reective distinction should be understood, in any
case, more as a continuum than a dichotomy.
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L. Sass & J. Feyaerts
Historical Antecedents
The relevance of such inwardness and associated alien-
ation has long been recognized in classic psychiatric ac-
counts of schizophrenia that are attuned to the subjective
dimension. The importance of inwardness is already evi-
dent in Eugen Bleuler’s notion of “autism,”32 which refers
to the turning-away from the external and social world
that he viewed as a dening symptom of schizophrenia.33
Both Eugene Minkowski’s “loss of vital contact”26 and
Wolfgang Blankenburg’s “loss of natural self-evidence”34
(of the sense of obviousness or the taken-for-granted)
reect this turning inward. Together they capture the
accompanying alterations of external and social reality
(heightened alienation, devitalization, derealization; a
sense of things being uncertain and arbitrary) that pre-
vail, often giving rise to metaphysical questioning and
“existential reorientations.”35,i
The hyperreexive aspect is perhaps clearest in Klaus
Conrad’s inuential account of early schizophrenic
symptoms, which he describes as involving a two-
faced alteration, simultaneous and complementary,
in the experience of both world and self.36 These are
rst, the Apophany: a heightened awareness of uncanny
iExaggerated self-reection is explicit in Blankenburg’s account of “loss of
natural self-evidence,” though Blankenburg presents such self- consciousness
largely as a product (a defensive reaction) rather than source for this under-
mining of the obvious or taken-for-granted.34
Fig. 1. Ipseity-Disorder Model (IDM) and Ipseity-Disorder Model Revised (IDMRevised)
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Self-Disorder in Schizophrenia: Revised View (2)
meaningfulness or signicance (the term derives from
the Greek for “to become manifest”), and second,
Anastrophe: a “stepping-back” from normal absorbed
experience that Conrad describes as a turning-inward,
auto-observation, “permanent consciousness,” or
“spasm of reexion” that suppresses one’s normal and
spontaneous world-orientation and “living toward the
future.”
The Japanese psychiatrists Kimura Bin37 and Nagai
Mari38 describe a kind of constant and involuntary
“self-witnessing” as the key feature. Their subtle but
difcult account of self-witnessing brings out the in-
herently paradoxical aspect of schizophrenic selfhood,
involving both a heightened self-presence and a simul-
taneous sense of an alien subjectivity within—and
even, the achieving of heightened self-presence only at
the cost of a certain alienation from one’s immediate
subjectivity. Kimura and Nagai describe the kind of
self-consciousness found in schizophrenia as unusual
insofar as the consciousness that is somehow watched
by itself does not thereby lose its quality as conscious-
ness or as a gazing upon the world (ie, its awareness
of a certain “for-me-ness” of its own experience). Such
paradoxical forms can hardly be captured by a simple
notion of diminished self-presence or minimal self, since
they incorporate the increased (albeit paradoxical) self-
presence that is inherent in a more acute experience of
oneself as a knower.
The term “hyperreexivity” was introduced through
discussion of the myriad parallels between classically
schizophrenic experience and expression and that typ-
ical of the modernist and postmodernist art, literature,
and thought of the 20th century—ie, of artists (and
movements) who turned the normally tacit foundations
of both art and experience into the main subject of
their work.28 Such artists and movements engendered
all manner of conceptual and experiential contradic-
tions—and did so by taking subjectivity or mental life
as both the prime object of attention and the “sover-
eign subject” or constituting center of all that exists (as
what Foucault termed the “empirico-transcendental
doublet”39). Such contradictions are indeed “paradoxes
of the reexive.”28 The parallels between madness and
modernism can serve to illuminate schizophrenic phe-
nomena that are too readily dismissed as demented,
regressed, or simply incomprehensible, but that, in
fact, demonstrate the peculiar, and often paradoxical,
patterns inherent in such inwardness, alienation, and
reexivity.28,40,41
Let us return to the experiential abnormalities de-
scribed in our rst article, but considering them now in
light of “hyperreexivity.” We consider, rst, manifest-
ations of exaggerated self-presence—whose association
with hyperreexivity might seem particularly obvious.
Then we consider diminished self-presence before turning
to various paradoxical manifestations.
Hyperreexivity and Exaggerated Self-Presence
The hyperreexive aspect of exaggerated self-presence
is, perhaps, almost too obvious to require elaboration.
It would seem that exaggerated self-presence just is a
heightened awareness of one’s own being aware. It is,
after all, a bringing-to-the-fore of something that would
normally be taken-for-granted and thereby recede to the
background, or, perhaps, would not be registered in con-
sciousness at all—ie, the sheer fact of existing as, or of
having, a eld of conscious awareness (and thus: of the
“for-me-ness” of the experienced world).
Derealization and Exaggerated Self-Presence: Patient
complaints regarding the fraudulence, imsiness, or
ephemeral quality of experiential objects—very common
in schizophrenia42,43—may reect how the world can seem
derealized in the presence of this hyperreexive self-
awareness of awareness as such: “I see things devoid of
substance [ . . . ] what I see is only a play, a Punch and
Judy show; it is clumsy, vulgar, unpleasant and, above
all, false; it doesn’t really exist.”44 “There is no reason for
believing in the existence of an unobservable like an ex-
ternal world, and therefore my mind, cluttered with sur-
prisingly uncooperative images, is my only reality.”45
Here the “for-me-ness” seems to be exacerbated and
extended, not diminished: A person who experiences
even real-world objects, persons, or events as lacking a
certain independence and solid reality may be hyperaware
of her own consciousness as the (constituting) medium
of experience, and therefore of objects in the external
world as having what might be termed a “coefcient of
subjectivity.”46
Increased Grip and Exaggerated Self-Presence
Exaggerated for-me-ness seems relevant as well for ex-
aggerated grip, whether in what we have described (in
Article 1) as its mystical or its ontologically paranoid
form. In the mystical case, a heightened sense of coher-
ence and salience evokes feelings of higher unity or mys-
tical wholeness, such that patients feel directly aligned
with ultimate aspects of reality that may have previously
remained hidden.47,48 Here there seems a homogenization
and effacement of boundaries: the signicance of mind-
world or subject-object distinctions recedes in the pres-
ence of a hyperreexive awareness that renders all things
quasi-subjectivized and thereby equivalent.
In the paranoid case, the sense of oneself as the con-
scious center of things grounds the feeling that other
conscious centers must be attending to oneself as the ul-
timate centerpoint and therefore as the target of greatest
interest. This hyperreexive interpretation of paranoia
may also account for its often “ontological” character in
schizophrenia (cf. article 1), ie, the fact that such para-
noia is often not limited to particular persons or entities
(as would be the case in, eg, delusional disorders),49 but
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L. Sass & J. Feyaerts
tends to extend to the whole of reality, eg, as involving
impersonal gazes or cameras that possess a ubiquitous
or allover mode of presence, both internal and external.
One patient is “examined throughout my life—se-
cret cameras and microphones whirring in my head.”50
“There was something there,” said another, “beneath
me, behind me, between and above me. Everywhere and
always.”42
The prominence of hyperreexivity (though not
the term) is essential to the French psychiatrist Henri
Grivois’51 account of schizophrenia as being grounded,
in its origin and essence, in the patient’s experience of
his own centrality in the universe (“centration”) and of
everything being somehow concerned with or directed
toward him (“concernement”)—as discussed in our pre-
vious article. And these, in turn, could obviously account
for what, since Bleuler, have been recognized as the most
common delusions in schizophrenia: those involving a
sense of grandiosity or of persecution—delusions that,
in their specically schizophrenic form, appear to be
grounded in a fundamental alteration in the way in which
self and reality-in-general are being experienced.ii
Hyperreexivity and Loss-of-self
Experiences of diminished self-presence may seem, at
rst, to be antithetical to all that has just been described,
yet they too can be bound up with hyperreexivity.
One route is already elaborated in the IDM1,2 and earlier
in Sass’s Madness and Modernism28: a hyperreexive
focusing or concentration on aspects of experience
that would normally be lived through in an implicit
manner—and would thereby serve as the medium of a
sense of self—can result in these dimensions of experi-
ence being objectied, alienated, or reied. (This may af-
fect, eg, the inner speech supportive of thinking or the
kinesthetic and proprioceptive sensations of the body.)
In the current IDM this is described as undermining a
supposedly normal and constant sense of implicit self-
presence (“minimal self”). It can also be thought of
as disrupting the spontaneous ow of absorbed expe-
rience: as inserting self-related stimuli into what might
otherwise have been a transparent, world-directed, or
meaning-directed ow.22
In accord with either interpretation, the patient may
well be expected to complain of a certain “loss of self ”—
referring thereby either to a loss of implicit self-presence
that would normally be present, or simply to a disappear-
ance of a familiar kind of engaged spontaneity. “You’re
on automatic pilot and you’re an observer,” reported one
patient. “You’re doing all kinds of stuff but it’s like you’re
not really present, as if you’re observing everything from
your own perspective. When you’re observing, you par-
ticipate less.”42
Some such experiences of loss-of-self may result from
operative hyperreexivity, in which disruptive sensations
seem, so to speak, to pop out in an automatic or non-
volitional fashion and interrupt more spontaneous or
habitual modes of awareness and action. Others may in-
volve more reective forms of hyperreexivity, in which
self-directed attention would have a more secondary as
well as a partially volitional quality. The patient may, eg,
attend in a somewhat intentional or goal-directed fashion
to normally implicit sensations of which she nds her-
self becoming aware (or to other kinds of abnormal per-
ceptual experiences felt as unusual),iii perhaps in order to
monitor or somehow control their disruptive effect—even
though (as noted above) this very attentiveness is liable to
exacerbate the very alienation or abnormality she is at-
tempting to control.
Something like this hyperreexive progression has been
documented in longitudinal studies regarding the devel-
opment of schizophrenic “rst-rank symptoms” from the
initial and underlying subjective phenomena known as
“basic symptoms.”52 The symptom sequence begins with
a kind of “basal irritation,”53 a disconcerting awareness
of alterations in one’s experience of perceiving, thinking,
or the body, often involving sensations that would nor-
mally have remained in the experiential background (a
kind of operative hyperreexivity). Patients who eventu-
ally developed symptoms involving loss of bodily posses-
sion, for instance, had earlier experiences of “irritating
disturbances of bodily feelings or cenesthesias,” such as
electrical or migrating sensations or subtle feelings of
enlargement or diminishment of body parts.53 Over time
such awareness becomes increasingly acute, inspiring
subtle experiences of “somatopsychic” or “allopsychic
depersonalization or derealization” that are accom-
panied, as well, by “complicated processes of adaptation
and coping,” including “checking efforts” and attempts
to give meaning or exert control over these emerging
sensations (reective hyperreexivity)—all this typically
leading eventually into classic symptoms of truly not
owning one’s own thoughts, or perhaps of one’s body
being inuenced from without.53
Here, it seems, the awareness and the experiential al-
terations should not be viewed as two separable things
(as if the rst were a mere noticing of the second). The
very fact of being so aware (so focally aware) may ac-
tually alter the experiences in question through a kind
of reication, a process whereby subtle background
iiSuch delusions should be understood not merely in terms of their mean-
ingful symbolic content and in relation to the patient’s biography (as
Bleuler and Freud often recommended) but in relation to the ontological
transformations that occur (which is more in accord with Jaspers’ views).
iiiHyperreexivity might sometimes be secondary to perceptual anomalies
that are not themselves necessarily hyperreexive in nature. We would nev-
ertheless argue that, when distinctively schizophrenic features develop, these
are likely to be bound up with hyperreexivity. See text re “attractor basin”
notion.
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forms of awareness are made to take on the more ex-
plicit qualities of an object of focal attention—thereby
manifesting what R.D. Laing aptly termed “phantom
concreteness.”46 Antonin Artaud, who suffered from
schizophrenia, experienced his own facial sensations,
normally lived tacitly from within, as taking the form of
a “vitreous” masklike membrane that seemed to rise off
from his own face.54
It should be noted, as well, that the very act of searching
for oneself can be understood as a futile and perhaps
counterproductive attempt—for as various philosophers
(Hume, early Sartre, and many Buddhist thinkers) have
argued, there may be no self if the latter is dened as
some necessary and constant object, or even as a reliable
sense of presence. In such cases, in fact, it may be the very
looking for something that, by its very nature, cannot ac-
tually be found, that brings on a sense or an awareness
of ungrounding that would not be present in normal, on-
going experience.
Hyperreexivity and Dualities of Disturbed Grip
The seemingly contradictory dualities of grip are
no less striking and no less explicable in light of
hyperreexivity.
A hyperreexive or self-conscious awareness of one’s
own centrality can naturally generate a sense of things
being organized around oneself or of being—oneself—
the prime object of all awarenesses. We have considered
how this may give rise to delusions of reference, the on-
tological paranoia of a “watcher-machine,” or the sense
of nothing being random since everything is somehow
organized in relation to oneself (usually the patient
cannot say just how). Antithetical developments can also
occur, however, given a second factor. This is the fact
that withdrawal from direct and vital engagement with
the external object-world—which can also be inherent in
hyperreexivity—may weaken or undermine the normal,
purpose-ridden affordances that lend pattern to one’s eld
of awareness, thereby undermining the normal sources of
organization and meaningfulness.55
These two possibilities correspond to the classic dis-
tinction made between two main types or syndromes
of schizophrenia, the “paranoid” and the “disorgan-
ized” or “hebephrenic” types. Research shows that these
classic subtypes do not in fact separate out very clearly,
with many patients showing both types of symptoms
at different stages of their illness or even manifesting
both disorganization and paranoia at the same time.56
(Recognition of this overlapping has led to elimina-
tion of the subtype designation in the latest diagnostic
system.) The common thread of hyperreexivity can
help explain how these two aspects—seemingly so op-
posed—might stem from a shared underlying core,
from different potentialities inherent in hyperreexive
withdrawal.
Symptom and Counter-Symptom: Paradoxes of the
Reexive
It appears, then, that hyperreexivity can capture the
co-existence of symptom and counter-symptom that (as
Vygotsky noted, see article 1) seems endemic to schiz-
ophrenic conditions. Diminished and heightened self-
presence; loosened and tightened grip; grandiosity and
paranoia: both sides of each of these dualities can be
understood as manifestations of the inwardness and al-
ienation implicit in this introversive form of existence.
These two sides of a coin are sometimes combined in
representative schizophrenic symptoms that capture their
paradoxical complementarity—as with the inuencing-
machine delusion whereby the patient Natalija posits her-
self as both the godlike center of all that appears and as a
mere machine manipulated by mysterious others.57
A closely related duality is apparent when Schreber
recounts how his paranoid sense of being watched and
controlled by the “nerves” and “rays” of God was inti-
mately related to his own quasi-divine importance as the
ultimate center of reality.58,59 It is perhaps not surprising
(indeed, perhaps is inevitable) that the one who feels him-
self to center or anchor the world (“I have the sensation
that everything turns around me” is a common schizo-
phrenic experience36), should also be the person toward
whom all meanings and messages are directed, the very
one whom everything concerns—as if everything orients
around oneself, rather like iron lings pointing toward
a magnet. In this sense centration and concernement are
complementary or mutually interdependent—two sides
of a coin. There may, however, be times when one or the
other takes the fore, leading to oscillations between a
more grandiose and a more paranoid orientation.
Here a useful analogy is that of a sniper who, peering
through his gunsight, naturally senses his own centrality
as the point-of-origin of what seems the all-powerful cone
of awareness that splays out before his own scrutinizing
eye, yet who must realize as well (all the while, or perhaps,
just before pulling the trigger) that all enemy glances might
seek out and potentially converge on him, thereby trans-
forming his own sovereign viewpoint into the target of a
kind of ontological “search-and-destroy” mission. This
might serve as a real-world analogy for the co-occurrence
(or possible oscillation) between exaggerated self-presence
and all-encompassing paranoia that are two aspects (an-
tithetical, yet also complementary) of a hyperreexive
awareness of the “for-me-ness” of the experiential world.
Two Models: “Hyperreexivity” vs “Diminished
Minimal Self”
Variability
We have noted hyperreexivity’s compatibility with, and
indeed, its ability to account for, the remarkable diversity
of schizophrenic phenomena—which includes seemingly
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L. Sass & J. Feyaerts
antithetical symptoms that might seem mutually exclu-
sive. Also signicant is this construct’s compatibility with
the variability of symptoms, referring now to how symp-
toms may wax or wane over time, sometimes imposing
themselves forcefully but at other times fading away.29,30
By contrast, “diminished minimal self” suggests a per-
sistent condition (and has indeed sometimes been un-
derstood as such)60 that is supposedly invariant, though
somewhat changeable in its expression; it refers to an un-
derlying state of being rather than to any process that may
have brought this state about. The concept has rightly been
criticized for its seeming inability to account for why sense
of self appears “relatively intact prior to illness onset” but
then is lost, and also for how this sense could possibly be
regained or reconstructed in processes of recovery.61
What hyperreexivity describes is, by contrast, some-
thing more like an orientation, a shifting form of atten-
tion or a tendency, a propensity to adopt a distinctive
kind of inward or alienated attitude that unsettles the
taken-for-granted and disrupts concentration and ha-
bitual forms of spontaneous ow. Like the self-centrality
it grounds, the tendency toward hyperreexivity may
be a latent vulnerability trait. It is understandable that
such an attitude might develop its own inertia and per-
sistence, becoming almost habitual, but also that it is
likely to wax and wane in accord with internal moods or
other states and in reaction to external events or inter-
personal experiences that may be experienced as threat-
ening or soothing62—and that these shifts may occur
spontaneously, as a mindset that can overtake a person
yet without being entirely beyond control. Recent meth-
odological developments in the modeling of psychopath-
ological dynamics63 may allow empirical conrmation of
these ideas, eg, by studying whether temporal increases
in hyperreexive patterns are predictive for the develop-
ment of psychotic symptoms, and/or whether decreased
hyperreexivity characterizes periods of remission and
recovery—thereby testing a phenomenological model of
the onset and development of schizophrenia-spectrum
disorders that can complement and enrich current pre-
diction approaches.64
Persons with schizophrenia describe such variability
and, with it, the possibility of having some modicum of
control.27 Patients do sometimes manage to quiet their
voices, often by engaging in familiar forms of practical
activity, like shoveling snow or washing the dishes.65,66
They may also bring on unusual experiences through
intense hyperreexive concentration that can bring
about a sense of self-alienation but also a sense of uni-
versal centrality.67 The latter propensity—for intense
concentration—may typically be described, in psychi-
atry, as a defect, deciency, or weakness, but could be
thought of equally well as a capacity, perhaps even a
kind of talent—for as Kimura notes, persistent “simul-
taneous reection” is something that normal or non-
schizophrenic people do not have the ability to sustain.37
Hyperreexivity and the “Natural Attitude”
Earlier we described the apparent variability of self-
presence in more standard and clearly non-schizophrenic
forms of experience (eg, variations of self-presence
in absorbed versus more self-aware activities or situ-
ations). What is it, we may ask, that differentiates these
from the diminishment or exaggeration of self-presence
characteristic of schizophrenia? Is it, for example, a
matter of type or of degree? Or is it related to the spe-
cic nature of the hyperreexivity that predominates in
schizophrenia68?
We have already suggested some differences intrinsic
to the state of consciousness involved (tacit-becoming-
explicit, the peculiarities of involuntary self-witnessing).
There may also be quantitative differences in the inten-
sity of the processes or in how often or long they persist,
or in the degree to which the person is able to exibly
modulate forms of tacit immersion and states of reexive
consciousness. But beyond this it may be necessary to
describe as well, certain limitations on how seriously
such changes are taken, given what could be described
as the person’s existential attitude or orientation.iv
For most “normal” individuals, indeed for most
people who are not in the schizophrenia-spectrum or cur-
rently psychotic, something like what phenomenologist
Edmund Husserl termed the “natural attitude” prevails
as an underlying foundation or overarching framework,
and as a set of constraints, regarding reality-in-
general, that persist as the underlying and unchangeable
framework of waking life. This includes assumptions,
normally too obvious to be spoken or thought, that
preclude either of the polarized extremes to which
hyperreexivity can lead: such “urdoxa” (foundational
presuppositions) as the fact that there is an external
world, that other subjectivities distinct from but akin to
us exist, and that one does oneself exist (though without
any insistence on its being in every moment recognized
from within). One may ask whether it is the fragility of
a person’s grounding in this attitude and its urdoxa that
makes schizophrenic hyperreexivity possible or distinc-
tive (for this suggestion, see70,71): perhaps only then can
a person engage in such inward, unconventional, and
alienating forms of self- consciousness which can lead
to extreme experiences either of loss-of-self or of its
apotheosis. Or to the contrary, is it that hyperreexivity
undermines the urdoxa—which, as it were, can be sus-
pended or even dissolve under the hyperreexive gaze?
The hyperreexivity characteristic of schizophrenia
often has a “transcendental” avor, given its tendency to
“bracket” or set aside the “natural attitude” that is pre-
supposed in normal forms of both consciousness and
ivRe the typical alterations of attitude and orientation in schizophrenia-
spectrum, see EASE section V35 and EAWE section VI69 (which are highly
overlapping).
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Self-Disorder in Schizophrenia: Revised View (2)
self-consciousness—ie, to take “subjectivity” rather than
objective reality as primary. (By contrast, the natural at-
titude is interpersonally grounded, practically oriented,
and typically realist regarding external reality72).v
These two dimensions—hyperreexivity and lack of
adherence to the natural attitude—seem in any case to be
intimately related.28,47,74,75 Together they seem to capture,
if not the “essence” (which may not exist) then at least
the distinctive signature of the diverse yet real unity, of
that nest of paradoxes—human, all-too-human—that is
schizophrenia.
Implications for Research and Treatment
This revision of the IDM (see gure 1A and B) has im-
plications for both research and treatment. Consider
rst the issue of neural correlates and neurobiological
modeling.
The Neural Plane
The minimal-self model would seem to motivate, most
naturally, a search for a shared neural factor that (sup-
posedly) would underlie the various forms of diminished
minimal self-experience—almost a kind of holy grail
that would index and perhaps account for this suppos-
edly key abnormality that is assumed to lie at the core
of the overtly diverse abnormalities of schizophrenic ex-
perience. Hyperreexivity suggests an orientation that is
more diverse and modest in its ambitions—and more in
line with current empirical research on neurobiological
correlates.
The neural correlate in question would, of course,
be expected to be associated not primarily or exclu-
sively with diminished self (nor with the hypothesis of
diminished meta-cognitive awareness76), but with the
forms of self-conscious introversion captured by the
hyperreexivity notion. And these, in turn, might be
expected to be heterogeneous, given the diverse ways
in which “hyperreexivity” may occur—eg, sometimes
as an automatic popping-out of kinesthetic sensations
that would normally have been unnoticed or suppressed
(“operative hyperreexivity,” perhaps bound up with sa-
lience dysregulation77); sometimes as a more purposive
scrutiny of background sensations or assumptions (“re-
ective hyperreexivity,” perhaps bound up with hemi-
spheric irregularities78); and still other times as passivized
withdrawal from practical activity underlying exagger-
ated experiences of inwardnesss and personal centrality
(perhaps correlated with hyperactivation of the DMN:
Default Mode Network79) or else confusion regarding
what is experienced as being “inner” versus as “outer”
(perhaps correlated with unusual positive correlation
of DMN with the CEN: Central Executive Network80).
Rather than a unipolar abnor mality, there seems a general
instability—reected, eg, in predictive-processing studies
showing weaker but also stronger “priors” in psychosis,81
or in DMN activity/connectivity being sometimes weak-
ened but other times strengthened.82
We suspect that, rather than having any single neurobi-
ological correlate, schizophrenia needs to be appreciated
in its diversity—the heterogeneity of its symptoms going
along with a heterogeneity of neural correlates. The unity
underlying (or coexisting with) this diversity may need
to be identied on the psychological and indeed the phe-
nomenological plane—as involving what might be termed
a nal common pathway, a “real or “robust pattern,”83
a kind of “attractor basin”84 (or “strange-attractor”
basin85—allowing for heterogeneity and uctuations)
whereby the different aspects of hyperreexivity (in both
operative and reective forms) occur in a variety of both
causally interacting and mutually implicatory ways.4 Such
a basin could, of course, have a variety of more distal
causal factors, both genetic and environmental.
Psychological Treatment
Implications for treatment were addressed at the end of
the previous article. There we discussed the nature of
heightened self-presence and tightened grip, an appreci-
ation of which can help overcome the tendency either to
nd such experiences incomprehensible and alien, or else
to oversimplify by viewing them as forms of secondary
defense potentially subject to intellectual or cognitive ref-
utation. It helps the clinician to appreciate the central im-
portance of centration itself, and thus of key symptoms
such as delusions of reference, grandiose delusions, and
delusions of omniscience.
The most signicant implications may pertain less to
any specic therapeutic technique and more to an at-
mospheric shift.86 This would involve overcoming a kind
of epistemic injustice that is widespread and difcult to
dislodge: that of condescending to the patient’s perspec-
tive by viewing it not only as inaccurate but as somehow
less developed or mature than that of the non-psychotic
individual.87 Instead of viewing the seemingly contradic-
tory claims as indicating failures of logic or regression
to primitive modes, “hyperreexivity” allows them to
be, at least in some instances, appreciated as higher-level
paradoxes, indeed as “paradoxes of the reexive.”28,39,40
Final Comment
The central role of hyperreexivity (especially of tran-
scendental hyperreexivity) for understanding schizo-
phrenia is, of course, only a hypothesis, and will need,
over time, to prove its superiority to alternative hypoth-
eses. Here we have argued that hyperreexivity accords
with the diversity of symptoms in schizophrenia; can
vWe speak of transcendental hyperreexivity by analogy with Husserl’s
“transcendental” versus “empirical” forms of reection.73
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L. Sass & J. Feyaerts
account for its distinctive paradoxes; and offers a way of
understanding its agentic ambiguities and of conceiving
its variability over time. We have suggested various em-
pirical and practical implications. We note as well that
whereas diminished “minimal self” suggests a loss of
the kind of self-consciousness that seems almost den-
itive of human nature, “hyperreexivity” views schizo-
phrenia squarely within the human domain—indeed, as
an exaggeration of forms of awareness (involving self-
consciousness and self-questioning) that are likely to be
unique to our species.
Acknowledgments
The authors want to thank Barnaby Nelson, Marino
Pérez Álvarez, Wouter Kusters, Stijn Vanheule, Matt
Millar, and several anonymous reviewers for their helpful
feedback on earlier versions of this article.
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