Sei sulla pagina 1di 45

Univ. of California San Diego 132.239.1.231 - 3/10/2017 3:39:00 AM

Downloaded by:

Diego 132.239.1.231 - 3/10/2017 3:39:00 AM Downloaded by: Psychopathology 2017;50:10–54 DOI: 10.1159/000454928
Diego 132.239.1.231 - 3/10/2017 3:39:00 AM Downloaded by: Psychopathology 2017;50:10–54 DOI: 10.1159/000454928
Diego 132.239.1.231 - 3/10/2017 3:39:00 AM Downloaded by: Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

Received: August 11, 2016 Accepted after revision: December 2, 2016 Published online: March 8, 2017

EAWE: Examination of Anomalous World Experience

Louis Sass a

Elizabeth

Pienkos b

Borut Škodlar c

Giovanni Stanghellini d, e

Thomas Fuchs f

Josef

Parnas g

Nev Jones h

a Rutgers University, Piscataway, NJ, and b University of Hartford, West Hartford, CT, USA; c University of Ljubljana, Ljubljana, Slovenia; d G. d’Annunzio University, Chieti, Italy; e Diego Portales University, Santiago, Chile; f University of Heidelberg, Heidelberg, Germany; g University of Copenhagen, Copenhagen, Denmark; h Felton Institute, San Francisco, CA, USA

Keywords Phenomenological psychopathology · Schizophrenia · Lived world · Qualitative/semi-structured interview · Spatial experience · Interpersonal experience · Temporality · Phenomenology of language · Derealization · Existential orientation

Abstract The “EAWE: Examination of Anomalous World Experience” is a detailed semi-structured interview format whose aim is to elicit description and discussion of a person’s experience of various aspects of their lived world. The instrument is grounded in the tradition of phenomenological psychopa- thology and aims to explore, in a qualitatively rich manner, six key dimensions of subjectivity – namely, a person’s expe- rience of: (1) Space and objects, (2) Time and events, (3) Oth- er persons, (4) Language (whether spoken or written), (5) At-

Louis Sass and Elizabeth Pienkos are joint first authors of this work.

© 2017 S. Karger AG, Baseland Elizabeth Pienkos are joint first authors of this work. E-Mail karger@karger.com www.karger.com/psp mosphere

E-Mail karger@karger.com

www.karger.com/psp

mosphere (overall sense of reality, familiarity, vitality, mean- ing, or relevance), and (6) Existential orientation (values, attitudes, and worldviews). The EAWE is based on and primarily directed toward experi- ences thought to be common in, and sometimes distinctive of, schizophrenia spectrum conditions. It can, however, also be used to investigate anomalies of world experience in oth- er populations. After a theoretical and methodological intro- duction, the EAWE lists 75 specific items, often with sub- types, in its six domains, together with illustrative quotations from patients. The EAWE appears in a special issue of Psychopathology that also contains an orienting preface (where the difficulty as well as necessity of studying subjective life is acknowl- edged) and a brief reliability report. Also included are six ancillary or background articles, which survey phenomeno- logically oriented theory, research, and clinical lore relevant to the six experiential domains. © 2017 S. Karger AG, Basel

Louis Sass, PhD Department of Clinical Psychology, GSAPP, Rutgers University

152 Frelinghuysen Road

Piscataway, NJ 08854 (USA) E-Mail lsass@gsapp.rutgers.edu

Elizabeth Pienkos, PsyD Department of Psychology, University of Hartford

200 Bloomfield Ave.

West Hartford, CT 06117 (USA)

E-Mail epienkos@gmail.com

132.239.1.231 - 3/10/2017 3:39:00 AM

Univ. of California San Diego

Downloaded by:

Introduction

The Examination of Anomalous World Experience (EAWE) is a semi-structured interview designed to explore subjective anomalies in a person’s experience of the external world, language, and other people, i.e., his or her “lived world.” It is primarily but not exclusively based on experi- ential and clinical accounts offered by and about individu-

als with schizophrenia spectrum disorders, and should have significant descriptive, differential, diagnostic, and perhaps prognostic relevance for these and other disorders. This presentation contains: (1) an introduction treating theoret- ical and practical issues; (2) a sequence of EAWE items cov- ering 6 domains of experience (Space and objects, Time and events, Other persons, Language, Atmosphere, and Exis- tential orientation); and (3) Appendix A: a listing of all EAWE items and subtypes for use during the interview. A version of Appendix A, formatted for use as a scoring sheet,

is available online as supplementary material. Appendix B,

a list comparing EAWE items with similar items from the

EASE (Examination of Anomalous Self-Experience) and the BSABS or Bonn Scale (Bonn Scale for the Assessment of Basic Symptoms/Bonner Skala für die Beurteilung von Basissymptomen), is also available as online supplementary material. (See www.karger.com/doi/10.1159/000454928 for all online suppl. material.)

Goals and Theoretical Considerations Disorders of the lived world – including anomalies in experience of space and objects, time and events, persons, language, overall atmosphere, and attitudes toward exis- tence – have long been recognized as key features of schizophrenia spectrum disorders. They are prominent in autobiographical accounts and other first-person re- ports as well as in clinical and psychopathological de- scriptions, both classic and contemporary. Some of these anomalies are collected and described in the BSABS [1]. The anomalies at issue have not, however, been organized and brought together in a single, synoptic list that is both comprehensive and richly detailed, and suited to the pur- pose of a general, empirical-phenomenological explora- tion of qualitative abnormalities of the lived world. The EAWE (pronounced ee wee) focuses primarily on experiential anomalies common in (though not necessar- ily unique to) the schizophrenia spectrum; it can be used, however, for exploring various disorders. The EAWE fo- cuses not on the more florid and overt symptoms crucial for standard diagnoses (such as hallucinations, delusions, and “negative” symptoms) but on assessing an underly- ing orientation or vulnerability manifest in subtle altera-

EAWE: Examination of Anomalous World Experience

tions in the person’s experience of or subjective perspec- tive on the lived world. Taken together, the six domains of the EAWE are intended to cover all major domains of world experience. Although it is likely to have some diagnostic signifi- cance, the EAWE is not intended to be used alone as a diagnostic instrument; the symptoms or experiential fea- tures it focuses on are mostly peripheral to or absent from standard diagnostic systems such as the DSM (Diagnostic and Statistical Manual of Mental Disorders) and ICD (In- ternational Classification of Diseases) (though perhaps relevant for a future, more phenomenological system). It can be used for evaluation, for research, and for insight into the texture, structure, and aspects of the dynamics of subjective life, as well as for developing and communicat- ing deeper understanding about the interviewee’s illness and personal perspective, which can be helpful in psycho- therapy and for other clinical purposes. The EAWE is a complement to the EASE [2], a semi- structured, phenomenologically oriented interview that focuses on disturbances of basic, minimal, or core self- awareness (“ipseity”). The EAWE was developed to cap- ture those aspects of schizophrenia that pertain more di- rectly to the experience of and orientation to the external world. Self-experience and world experience are, howev- er, closely intertwined and sometimes overlapping: virtu- ally all phenomenologists have emphasized the intimate relationship between subjective and objective aspects or poles of the act of consciousness (for further discussion, see Sass et al. [3]). Accordingly, distortions of “ipseity” or basic self-experience might be expected to be correlated and interconnected with a loosening or other distortion of what might be termed the “grip,” “hold,” or “grasp” that the subject has on the world [4, 5]. In this sense, no absolute distinctions are possible; in- deed, the distinction between the EASE and EAWE is necessarily somewhat arbitrary. Consider the EAWE do- mains of Time and events, Other persons, and Language (Domains 2, 3, and 4). Time is obviously a basic dimen- sion of worldly experience; yet basic or implicit temporal- ity [6], what William James [7] termed the “specious pres- ent,” is also the very medium of basic self-experience. Awareness of persons or other subjectivities is bound up with self-consciousness. Language derives (as a system) and arrives (as the speech or writing of others) from the social world, yet it is also incorporated by and into the subject; only thus does it come to frame our experience of external objects and events. It is, therefore, to be expected that certain EASE items would be relevant to the domains captured in the EAWE.

Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

11

Univ. of California San Diego 132.239.1.231 - 3/10/2017 3:39:00 AM

Downloaded by:

Those EASE items that pertain rather directly to world experience are, therefore, also included in the EAWE, e.g., Domain 6, Existential orientation. Equivalent EASE (and Bonn Scale) item numbers are noted when they are used in the EAWE, and a full table listing similarities and over- lap with the EASE and the Bonn Scale is available as on- line supplementary Appendix B. In addition, mutations of worldly experience (like mu- tations of ipseity or basic self-experience) typically have an overall or holistic character that defies ready opera- tionalization into distinct features or factors. Time and space, for example, are not independent features of our worldly experience but interdependent dimensions or forms of experience that vary together in certain ways [8]. Also, our experience of space and the object world is typ- ically imbued with an implicit sense of the presence of other conscious beings (the Domain Other persons), po- tential viewers with different angles of vision [9]. Particu- larly difficult to capture are atmospheric or pervasive mood-like qualities, which one informant compared to the very “smell” of an experience. None of this should, however, be allowed to diminish the humanistic interest or scientific importance of the subjective domain. We recognize the on-principle impossibility of pro- ducing an operational rating system that does full justice to the complex flow or flux that is lived experience. The items listed in the EAWE are an attempt to strike a bal- ance between needs for operationalization and for cap- turing holistic, often elusive aspects of the experiential changes in question 1 . The individual items of the EAWE should, therefore, not be conceived of as describing dis- tinct symptoms that typically occur independently of one another. Often, several EAWE items may address a single, underlying, structural mutation of experience, as consid- ered from different standpoints or angles (e.g., its spatial aspect, its temporal aspect, etc.). The structure of the EAWE reflects, therefore, various (and at times conflict- ing) theoretical, practical, and experiential interests. As much as possible, notes are provided within the text to remind the interviewer of other items throughout the EAWE that are structurally similar to, or that frequently co-occur with, the item or subtype at hand.

Development of the EAWE The items of the EAWE are derived from clinical-phe- nomenological accounts or first-person descriptions tak- en from the psychopathological literature on schizophre- nia and related conditions and, on occasion, from the au- thors’ clinical experiences. The items have been refined through trial interviews using versions of the EAWE, and

12 Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

also through conversations and correspondence with persons with schizophrenia or other psychoses 2 . Based on feedback from interviewees during the trials and from other correspondents, the authors made revisions and additions to improve clarity, ease of use, and compre- hensiveness of the interview. We are much indebted to both the Bonn Scale 3 and the EASE; some of our items are derived directly or fairly directly from items in those scales. These items are in- dicated with the initials “BS” or “EASE” followed by the corresponding item number in the appropriate scale. Oth- er items reflect aspects of experience that are similar, though not identical, to Bonn Scale or EASE items. Identical or nearly identical items are indicated with a “ = ” sign; those that are partially similar, or where there is partial concep- tual overlap, are indicated with a “” sign. (Appendix B, which displays these similarities with EASE and Bonn Scale items in list form, is included as online supplementary ma- terial.) In addition to drawing on these two instruments, EAWE items and their descriptions are generally grounded in phenomenological theory (particularly philosophers Husserl, Heidegger, and Merleau-Ponty, and psychiatrists Minkowski, Conrad, and Blankenburg) along with both contemporary and classic works on psychopathology. Ref- erences are provided for exact quotations (except for quo- tations from our own patients or research subjects, which are listed as “unpublished data”) presented as examples and occasionally within item and subtype descriptions.

Auxiliary Items or Subtypes Some items and subtypes in the EAWE are included even though they do not seem more common in schizo- phrenia spectrum conditions than in certain other abnor- mal conditions, especially severe affective disorders and forms of paranoia. These are included because (1) they are frequently found in the schizophrenia spectrum; (2) they help to fill out the logic of the system; and (3) they may be useful in comparative studies. Such items and

1 There is a sense in which many or most EAWE items are somewhat “at- mospheric”/holistic. However, if the pervasive change pertains specifically to space, time, persons, or language, it is included in one of those domains, while Domain 5, Atmosphere, particularly foregrounds the more holistic aspects of experience.

2 The trials included the interviews from both reliability studies (US and Slovenia sites) as well as other interviews (not included in the reliability stud- ies) with 10 individuals with a range of psychiatric diagnoses (schizophrenia, schizoaffective disorder, schizotypal personality disorder, major depressive disorder, bipolar I, depersonalization disorder, acute psychosis, and obses- sive-compulsive disorder).

3 We have used the English edition of the Bonn Scale published in 2008 [1].

Sass/Pienkos/Škodlar/Stanghellini/Fuchs/

Parnas/Jones

132.239.1.231 - 3/10/2017 3:39:00 AM

Univ. of California San Diego

Downloaded by:

subtypes are indicated with an asterisk (“starred”) after the item/subtype label. Some starred items/subtypes may also represent experiences that might have a specific schizophrenic variant, but whose distinctiveness is diffi- cult to capture and may require further investigation 4 . Such challenges in defining and assigning the noso- logical status to psychiatric signs and symptoms are en- demic to modern psychiatry, perhaps especially with re- spect to schizophrenia. Here, we do not attempt to take a particular stance on the diagnostic significance of any of the EAWE items. The asterisks simply register our best judgment (on a simplified either/or basis) regarding what, according to most of the classic psychopathological literature, would or would not be considered highly dis- tinctive of schizophrenia (or the schizophrenia spec- trum), in contrast to other “functional” psychoses (severe forms of major depressive disorder, bipolar disorder, or delusional disorder) 5 . Indeed, one potential use of the EAWE is to establish just which forms of world experi- ence are, in fact, most discriminating for the schizophre- nia spectrum compared to various other conditions. Some subset or weighting of EAWE items may well prove useful for prediction studies or differential diagnosis. One should also not assume, of course, that there must be some single way in which world experience in schizophre- nia or other conditions is altered; it is possible that the possible modes or mutations of worldhood in schizo- phrenia are heterogeneous, though perhaps also interre- lated. A few examples of these starred items or subtypes are:

1.8.7 Affective experience of space*, 2.1.1 Time or move- ments seem speeded up*, 3.4.1 Feelings of self-conscious- ness or self-criticism*, 5.15.1 Mystic union with the world*, and 6.6 Impossible responsibility or guilt*. Al- though such experiences should be queried like any other item or subtype, they may need to be treated separately in data analysis.

General Guidelines for Conducting the Interview

Intrinsic Difficulties of the Interview In general, the EAWE targets experiences that the in- terviewee will recognize as being anomalous, in the sense

4 For an example of an attempt at such specification, in this case regarding first rank symptoms, see Koehler [10].

5 Potential overlaps with other disorders that may have some significant symptomatic affinities with schizophrenia, such as depersonalization disor- der or other dissociative conditions, are not indicated.

EAWE: Examination of Anomalous World Experience

of differing from what the interviewee takes to be the nor- mal experience of most other people, or believes to be characteristic of his/her own experience in a more usual state or condition. The subjective experiences described in the EAWE are often strange, private, and fleeting, and many will, therefore, have an inherently ineffable quality, making them challenging to inquire about or describe. Some experiences may actually undermine one’s capacity for clear linguistic communication. In addition, descrip- tions of subjective experience can be subject to various forms of distortion and cannot simply be taken at face value; thus, it is necessary for both the interviewer and interviewee to be capable of and interested in examining together the experiences reported. It is also important to appreciate the role of metaphors, an indispensable feature of language often used to de- scribe experiences that are especially subtle, pervasive, or unusual. Metaphor, however, can be misleading as well as revealing; judgment is often required to determine wheth- er an interviewee’s account fulfills criteria for a given item or subtype.

Necessities The tone of the interview is crucial. Experience shows that clinical patients and research subjects often feel re- lieved to encounter an interviewer who is interested in (and familiar with) subtle, often disconcerting experienc- es, which they may never have disclosed to or discussed with others. But it is also possible for an interviewee to feel that intimate corners of his or her private life are be- ing somehow invaded, or to more generally feel reluctant or embarrassed to speak of phenomena that seem par- ticularly intimate or strange, and that are not typically mentioned in everyday life, or even in the psychiatric context. It is, therefore, important to convey a sense of neutral, nonjudgmental, yet caring rapport, devoid of merely voyeuristic or objectifying curiosity. To listen in a sensitive and informed fashion, the in- terviewer needs a basic understanding of both general psychopathology and phenomenological accounts of hu- man consciousness and psychopathology. Several core texts of phenomenological psychopathology are listed in the references to this document. Specific discussion of the EAWE domains (and relevant references) can be found in three articles by Sass and Pienkos and also in a series of ancillary articles devoted to each of the six EAWE do- mains (see Sass et al. [3] for these references). One should generally not attempt to interview persons who are acutely ill or severely psychotic; typically, some degree of clinical improvement and stability is necessary

Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

13

Univ. of California San Diego 132.239.1.231 - 3/10/2017 3:39:00 AM

Downloaded by:

to engage in the sort of conversation required for the EAWE. Also, some individuals with a long history of schizophrenia or other mental illness may be unwilling or unable to engage in detailed or reflective conversation concerning their experiences, possibly as a result of re- peated psychotic episodes or side effects of medication. Some individuals may also find it difficult to remember the sorts of subtle changes queried here, which may have preceded or accompanied a first break.

Conduct of the Interview The semi-structured format of this interview indicates that the interaction should have the feel of a mutual and exploratory conversation, not of a targeted interrogation. The aim is to discern experiential patterns from self-de- scriptions and to uncover the qualitative features of ex- periences and illuminate them through vivid self-de- scriptions. Thus, the goal is not to measure or to seek causal explanations. Following the phenomenological principle of the epoché, or bracketing (for further discus- sion, see Sass et al. [3]), the interview should avoid ques- tions of whether an experience was actually veridical or not, or what mechanism or theory (e.g., neurocognitive or psychodynamic) might explain it, except insofar as such interpretations were implicit in the original experi- ence itself. (Domain 6, Existential orientation, can be something of an exception, since it explicitly queries opinions or interpretations of experience or the world.) If the interviewee does speak in the latter terms, the interviewer should turn the conversation back to “the things themselves” in the sense of how the world ap- peared to the interviewee; this may mean asking the in- terviewee to indicate or describe some example of the experience in question, and exploring as fully as possible that specific instance. It is important for the interviewer to have a solid un- derstanding of the phenomena targeted by the EAWE. This allows exploratory questions to be posed in as straightforward a manner as possible, in the interviewer’s own words, and avoiding an overly intellectualized tone. To facilitate interviewing, crucial phrases have been put in italics. Glancing at the capitalized labels and italicized phrases can remind the interviewer (already familiar with the EAWE) of the essence of each item or subtype. In gen- eral, the conversation should involve a process of mutu- ally interactive reflection in which interviewer and inter- viewee jointly participate in the, at times, difficult process of distilling and clarifying the interviewee’s statements. At the start of the interview, it is usually helpful to say that the interviewee is not expected to have had all the experi-

14 Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

ences that he or she will be asked about, but also that, if a given description resonates with a particular experience without quite matching it, that experience should be mentioned to the interviewer. To better understand the subjective quality of the ex- perience, it will typically be helpful to ask for one or more examples of any phenomena that are endorsed (if they have not been offered spontaneously), and then to ask about various aspects and features of a given incident in as much detail as is necessary to achieve a reasonably good understanding of how it was experienced. (For in- terviewees who endorse numerous items, this may sig- nificantly lengthen the interview, and it may be helpful to break the interview into several sessions.)

Targeted Period The EAWE emphasizes pre- or subpsychotic experi- ences, but this need not mean that all psychotic experi- ences must be excluded from consideration. Certain “psychotic” phenomena (i.e., experiences clearly divorced from consensual reality such as hallucinations and delu- sions) are also included in the EAWE, as these may some- times occur and/or continue outside of acute psychotic episodes and may be important to fully understand the quality of a person’s lived world. (Also, like most such distinctions, that between “subpsychotic” and “psychot- ic” is not always crystal clear: see item 3.7, Disturbance of self-other demarcation for good examples.) Researchers may wish to consider whether or not they wish to include and score experiences that occur only during frank psy- chosis; if these are included, they should be noted as such. Similarly, experiences that only occur during childhood (prior to any prodromal period) should not be discount- ed, but also noted as such by the interviewer or rater. Ex- periences that occur only under the influence of psycho- tropic substances (though not psychiatric medications taken as prescribed) or physical illness should be ex- cluded. The EAWE items can be applied to various time peri- ods, depending on the goals and purposes of the study being conducted. (See beginning of Domain 6 for some possible questions [not required] regarding time frame.) A common practice is to assess experiences on a lifetime basis (as is customary with the EASE). Assessment could, however, also focus on the last 14 days, 3 months, year, or other periods.

Domain and Item Sequence Before beginning the EAWE, it is usually helpful to ask the interviewee about his or her experience of illness, in-

Sass/Pienkos/Škodlar/Stanghellini/Fuchs/

Parnas/Jones

132.239.1.231 - 3/10/2017 3:39:00 AM

Univ. of California San Diego

Downloaded by:

cluding any past hospitalizations or notable periods of difficulty, along with an open-ended discussion about what seems most important in the experience of the ill- ness, particularly regarding the experience of the outside world and of other people. This builds rapport and pro- vides an overall sense of the interviewee’s self-under- standing, while often supplying information or examples relating to specific items queried later in the interview. It is also possible to begin by asking about the patient’s life history, and then focusing on relevant experiences that may be mentioned. The decision of where to start within the EAWE should be contextually determined according to conversational flow. Generally, it is best to begin with questions about phenomena that are more neutral and less threatening, and then to move into more difficult and provocative domains. Items are ordered within each EAWE domain roughly in accord with this principle:

more straightforward questions generally precede those pertaining to phenomena that are more complex or po- tentially disturbing. If there is no contextual reason to begin elsewhere, it is appropriate to begin with Domain 1 and then move progressively through the sequences to Domains 5 and 6. Interviewers interested in a particular domain or do- mains may, however, elect to use only the most relevant section or sections. To the extent possible, all relevant in- formation regarding a particular item should be collected before moving on to the next item. When moving through the interview, the interviewer should be aware that more and more items may have already been touched upon and may not need to be queried separately. Although it is im- portant that each item be explored, it is thus not necessary to follow the items in the order listed; the natural flow of conversation will often lead into later or earlier issues on the item list. The appropriate way to introduce each domain is by asking the subject a general question, for example, in Do- main 3: “Have you ever noticed any changes in the way you experience other people?” (Domain 1, Space and ob- jects, might be broken down into various areas of percep- tion, with general questions about vision, space, hearing, etc., used to introduce the relevant parts of the domain.) Anything relevant that the subject says in response can then be queried in more depth, asking for details and ex- amples to capture the subject’s description as accurately as possible. When the subject has finished speaking spon- taneously about such experiences, the interviewer should go through the list of items, asking about each item, often following up with each subtype. If the interviewer is rea- sonably confident that an entire item is not applicable, it

EAWE: Examination of Anomalous World Experience

may not be necessary to query individual subtypes. How- ever, if the interviewer is uncertain, these subtypes offer prompts and a means of exploring experiences associated with the item. It should be noted that the interviewee’s statement will sometimes need to be categorized as more than one item or more than one subtype. For instance, the state- ment, “Objects are stage trappings, placed here and there, geometric cubes without meaning” should be scored as 5.2, Loss of affordances and 5.1.5, Loss of enticement quality* (“geometric cubes without meaning”), and as 5.1.4, Falseness (“stage trappings”). Subtypes are placed together (within a particular item) for descriptive rea- sons; there is no a priori assumption that subtypes neces- sarily share an underlying psychopathological or patho- genetic essence. Generally, a complete EAWE interview will take from 1.5 to 2.5 h to complete, though the length varies consid- erably depending on the interviewee.

Scoring In scoring the EAWE, the interviewer or rater (if dif- ferent) should score items and subtypes as 0 = definitely not present, 2 = definitely present, 1 = possibly present. Items or subtypes that were not asked about should be left blank. A rater may be unable to score a subtype for a given item, either because no subtype applies or because there is not enough information to determine which subtype ap- plies. In this case, the rater should score the item without indicating any subtype. He or she may, however, wish to note the reason(s) why no subtype has been scored; al- though not required, this may be useful depending on the purposes of the study. This scoring system generally fol- lows the system recently used in various EASE studies. The overall magnitude of the EAWE score (excluding asterisked items; see above) should presumably reflect the severity and pervasiveness of the distinctively schizo- phrenia-like alteration or abnormality in the subject’s ex- perience of the world. Depending on the purposes of the study, interviewers may wish to calculate the sum of all subtypes or of items only. Information about the differ- ential importance of individual items and subtypes will likely emerge from future research. As noted above, if a subject endorses an item or subtype, but the experience has only occurred during a period of drug use or acute physical illness, the item or subtype should not be scored.

Training Training in use of the EASE and/or EAWE is very helpful for developing an understanding of the nuances

Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

15

Univ. of California San Diego 132.239.1.231 - 3/10/2017 3:39:00 AM

Downloaded by:

and practicalities of both the EASE and the EAWE and for increasing interrater reliability. At the time of this publication, formal trainings in the EASE are being of- fered in Denmark (regarding EASE workshops and rele- vant materials, see www.easenet.dk); for training and consultation in use of the EAWE, interested researchers and clinicians are advised to contact one of the authors. As noted, the interviewer should be familiar with general psychopathology and especially schizophrenia spectrum disorders, as well as with the phenomenological perspec- tive on psychopathology.

Psychometric Properties Two initial studies show strong interrater reliability for the EAWE. In a study of 11 outpatient subjects and 1 inpatient subject, with both raters present during inter- views, κ values for individual domains ranged from 0.73 to 0.89, with an average overall κ of 0.79. A second study of 15 inpatient subjects considered ratings with one rater present for (and conducting) interviews, and the second observing taped interviews; average κ values for individ- ual domains ranged from 0.74 to 0.95, with an average κ of 0.84 6 [11] .

Domains and Descriptions of Items and Subtypes

1 Space and Objects

General Description. The 17 items in Domain 1 refer to a variety of anomalous experiences of objects or space, or of qualities of sensory input. Most items pertain to vision and experience of the spatial world, but other modalities are also included. The focus is on more stable or static aspects of the world (as opposed to forms of action, flow, or change over time).

1.1 Abnormal Intensity or Persistence of Visual Perceptions

Colors, light, or entire images are observed as either more or less intense than usual, as failing to fade into the background, or as lasting much longer than usual. This may be associated with increased or diminished sensi- tivity to visual stimuli.

1.1.1 Increase in Intensity of Visual Perceptions*

( BS C.2.2.1 )

Colors and light seem stronger or brighter. This may ap- pear as an increased sensitivity to visual perceptions, or as a change in perceptions themselves.

16 Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

• “Colours seem to be brighter now, almost as if they were lumi- nous.” [12]

• “What used to be green, had now become dark green. The col- or of a cornfield seemed different, more intense and harsh. Ev- erything seemed different and unnatural.” [13]

1.1.2 Decrease in Intensity of Visual Perceptions*

The subject states that colors and light seem faded, fainter, or dimmer. This may appear as decreased sensitiv- ity to visual perceptions or as a change inherent in the perceptual object itself.

• “It’s a dull world, it really is. I don’t think there’s any colors in that.” [unpublished data] (also score 5.1.2, Decreased intensity or substantiality*)

• “Colors are dimmer and so is the significance.” [14] (consider also 5.2, Loss of affordances)

1.1.3 Recurrence or Prolongation of Visual Stimuli

(=BS C.2.3.12) The subject continues to see things after they have gone from her visual field (“palinopsia”). This presentation may be continuous or recurring.

• “Sometimes, I still see things that are not there anymore, e.g., a car that has already passed by. They remain before my eyes for a while. …like a visual echo.” [1]

• “A hat, initially seen on one person, recurred, in its proper po- sition, on others.” [15]

• “I sometimes see abstract patterns I have seen some time be- fore. They persist for days at the same place in my visual field; when I move my head, they follow.” [1]

1.2 Blindness or Partial Blindness (=BS C.2.1)

The subject has the experience of his vision being blurred or unclear, or of a part of an object or the visual field being absent.

1.2.1 Blurred Vision* (=BS C.2.1.1)

Blurred, unclear or turbid vision. It can be either tran- sient or of longer duration, stable or fluctuating.

• “My vision has decreased. I see everything hazy and foggy like through a veil.” [1] (consider also 5.1.1, Remoteness of barrier (plate-glass feeling)*)

• “When reading, my vision is unclear, the letters blur before my eyes.” [1]

6 We wish to warn against premature use of factor analysis (since para- metric assumptions are violated in EAWE and EASE). The items should be considered as ordinal. Also, they are, in many cases, mutually implicative or even overlapping (as reflected in the scoring rules); the scale itself is divided, on theoretical grounds, into rationally structured domains.

Sass/Pienkos/Škodlar/Stanghellini/Fuchs/

Parnas/Jones

132.239.1.231 - 3/10/2017 3:39:00 AM

Univ. of California San Diego

Downloaded by:

1.2.2 Partial Seeing ( =BS C.2.1.3 )

The subject only perceives part of an object, with other parts missing from perception.

• “[W]hen somebody shows me his whole hand, I can see only the upper part of the last three fingers. The part above a line that runs diagonally down from the forefinger to the little finger is cut away.” [1]

1.2.3 Transitory Blindness (=BS C.2.1.2 )

A subject’s visual field, either entirely or in part, is tem- porarily absent from perception.

• “Whenever I want to focus on an object, it disappears before my eyes.” [1]

• “The way, the hen and the room suddenly were invisible.” [1]

1.3 Disturbances Involving Veridicality (Accuracy) of Visual Perceptions*

The subject reports having mis-seen visual objects (e.g., shadow seen as a snake), or seeing things that were clearly not there. The experience can be quasi-visual, as if midway between seeing and imagining. NB: The focus should be on the nature of the original experience rath- er than on a subsequent assessment. Also, the experi- enced reality status of these experiences (hence the sub- type) can sometimes be difficult to specify. If the subtype is not obvious, choose the most appropriate subtype or subtypes, recording any relevant details that might clar- ify the nature of the experience.

1.3.1 Visual Illusions*

The subject reports misinterpreting an actual external visual stimulus or percept as being something else entirely (with the subject recognizing that the experienced per- cept is not really inherent in the external stimulus). The experience may have a distinctly “as if” rather than literal quality. This is more severe than normal cases of mistak- ing something briefly out of the corner of one’s eye, or due to darkness, etc.; typically it persists despite closer or pro- longed inspection.

• “Things shape themselves; the round holes in the window- frames [the fastenings] become heads and seem to be biting at me.” [14]

• “On all the trees and bushes I saw, instead of the usual crows, dim outlines of pantomime figures, pot-bellied fellows with thin bow-legs and long thick noses, or at another time ele- phants with long trunks swinging.” [14]

1.3.2 Visual Hallucinations *

Experience of visual sensations or perceptions that have very little or no basis in external reality. The phenomena

EAWE: Examination of Anomalous World Experience

in question have at least a quasi-real or quasi-external quality (the subject may not, however, feel the experience to be fully objective or wholly equivalent to normal per- ceptions). Reporting of this item generally implies recog- nition, in retrospect, of the deceptive nature of the earlier experience.

• “I saw people’s skins emitting fine black and yellow rays; the air too became pervaded with other strange rays and layers…” [14]

• “All day I have been afraid of wild animals which race through the closed doors; they steal, slow and black, along the wall to hide under the couch and watch me from there…” [14]

• “The figures grouped themselves round me 3–6 meters away. Grotesque human figures…The figures were there in space, but as if they had their own private space, peculiar to themselves.”

[14]

1.3.3 Visual Pseudohallucinations * ( BS C.2.2.2 )

As in Visual hallucinations* (1.3.2), the subject experi- ences visual phenomena not grounded (or only minimally grounded) in any external stimulus; but here the subject is clearly aware during the experience itself that these phe- nomena have no basis in external reality.

• “[H]e often felt that he saw colorful objects sail through his field of vision.” [16]

1.4 Visual Fragmentation

Object or scene typically perceived as coherent whole appears to break apart or lose its unity.

1.4.1 Object Fragmentation

Single objects are seen as being composed of separated individual parts. It is difficult or impossible to observe a thing as a whole; fragmentation can involve things or per- sons. This may include decomposition or splitting apart of objects not just into component parts (e.g., a chair into legs, a cushion, etc.) but also into particles.

• “I have to put things together in my head. If I look at my watch I see the watch, watchstrap, face, hands and so on, then I have got to put them together to get it into one piece.” [17]

• “For I saw the individual features of her face, separated from each other: the teeth, then the nose, then the cheeks, the one eye and the other.” [18]

1.4.2 Break-Up of a Scene

A scene, landscape, or the surrounding world loses its cohesive unity; objects seem isolated, disconnected from their context, and perhaps less meaningful. This may be experienced as literal separation of objects from one an- other, or as a general feeling that objects are no longer related to one another. NB: If the subject attempts to com-

Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

17

Univ. of California San Diego 132.239.1.231 - 3/10/2017 3:39:00 AM

Downloaded by:

pensate for this disturbance by trying to put things to- gether consciously or effortfully, the interviewer may wish to note “conscious construction of context or scene.”

[19]

• “…infinite space, unreal, where everything was cut off, naked and isolated.” [18] (also score 1.8.5, Experience of infinite space)

• saw the environment only in fragments. …no appreciation

of the whole…only details against a meaningless background.”

[19]

• “Everything is in bits. You put the picture up bit by bit in your head. It’s like a photograph that’s torn in bits and put together again…If I move there’s a new picture that I have to put to- gether again.” [12]

1.4.3 Captivation of Attention by Isolated Details

(=BS C.2.9, = EASE 1.12.1) Certain details of an object or scene seem to stand out for no good reason, drawing the subject’s attention so that he may feel unable to turn his gaze or attention away. This may include a specific object, detail, or features (such as particular colors, lines, shapes, or textures) that would not normally be salient or attract attention.

• “Sometimes an object stands out. Then, my eyes have to fix this detail, like being spellbound, although I don’t want to attend to it.” [1]

• “Not only the colour of things fascinates me, but all sorts of little things like markings on the surface, pick up my attention too.” [12]

1.5 Disorganization or Disturbed Object Stability

A disturbance in perceptual integrity or organization of objects or scenes.

1.5.1 Disorganized Object Contours (=BS C.2.3.10)

Boundaries or contours of an object are perceived as disturbed, broken up, disintegrating, or otherwise compro-

mised. The subject may describe contours as showing “breaks, bending, curve, meandering.” [1]

1.5.2 Loss of Perceptual Stability (Fluidity or

Contamination) Things or objects change form or meaning or transform before one’s gaze. At an extreme, they may even appear to be two different objects at the same moment, akin to a pho- tographic double exposure (exemplified by “fluidity” and “contamination” in Rorschach responses).

“I don’t see entire objects, things or people…Objects no longer appeared stable. They would glimmer fitfully and become displaced, making everything appear as if it were in a state of flux.” [15]

18

Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

• “[P]atterns released from their cage, from their “apparent” im- mobility; now: buckling, waxing, swelling into waves, receding and diminishing.” [unpublished data]

• The subject sees an object simultaneously as an “intact green leaf” but also as “crumpled up.” [unpublished data]

1.6 Changes in Quality, Size, or Shape of Visual Perceptions

Objects appear to have changed in color, size, or shape (from what would be usually perceived).

1.6.1 Changes in Color of Visual Perceptions (=BS

C.2.3.4)

Colors appear to change specific hue – whether affect- ing certain objects or coloration of the whole visual field.

• “While one is reading, the white paper suddenly appears red and the letters green. The faces of others take on a peculiar brown tint…” [14]

• “Suddenly I seemed to look through yellow glasses. And at oth- er times, everything was intensely dark-red.” [1]

1.6.2 Micropsia/Macropsia ( =BS C.2.3.2 )

Objects are perceived as, or somehow felt to be, smaller or larger than they really are. The interviewer should note whether smaller or larger.

• “Everything was so small and far away.” [1]

• “The furniture seemed small and distorted, the room long and wide.” [1]

• “I was sitting listening to another person and suddenly the other person became smaller and then larger and then he

seemed to get smaller again ”

[17]

• “…but the nearer we approached each other, the taller she grew, the more she swelled in size.” [18]

1.6.3 Dysmegalopsia ( =BS C.2.3.11 )

“Objects appear as bigger on one side and smaller on the

other than they really are.” [1]

• “The objects appeared somewhat distorted, higher on the one side and lower on the other.” [1]

1.6.4 Metamorphopsia ( =BS C.2.3.3 )

An object’s shape is perceived as changed or distorted from its appearance in reality. NB: Unlike 1.5.2, Loss of perceptual stability, here the change has already oc- curred; also, it is not akin to photographic double expo- sure.

• “The commodities looked peculiarly different, changed and deformed.” [1]

Sass/Pienkos/Škodlar/Stanghellini/Fuchs/

Parnas/Jones

132.239.1.231 - 3/10/2017 3:39:00 AM

Univ. of California San Diego

Downloaded by:

1.6.5 Other Distortions ( =BS C.2.3.8 )

Visual percepts may be seen as “doubled, oblique, slanting, or reversed” [1].

• “For quite a while, I saw doubly.” [1]

• “The houses were all so lopsided, they didn’t stand straight.” [1]

1.7 Disturbances of Perceptual Distance or Object Juxtaposition

Various disturbances in estimating spatial distances or juxtaposition of objects.

1.7.1 Objects Seem Closer or Farther Away * ( =BS

C.2.3.1)

The subject perceives objects as being either closer or farther away than would seem normal, but without focus- ing on change in size (as with 1.6.2, Micropsia/macrop- sia). This may apply to both visual and auditory percep- tions. The interviewer should record whether closer or farther away. NB: Disturbance of this type may also be expressed by a disturbance in the estimation of distances in general, without reference to a particular object or percept.

• “Things seemed so far away; everything was in a distance.” [1]

• “All things seemed to have got closer, as if looking through a telescope.” [1] (consider also 5.1.1, Remoteness or barrier (plate-glass feeling)*)

• “Faint spatial irregularities distort my perceptions, deepening stairs and telescoping school corridors.” [20]

1.7.2 Disturbance of Relative Spatial Relationship

( Juxtaposition ) of Objects

The spatial relationship between, or juxtaposition of, objects, or their relative closeness to the perceiver, is dis-

organized or perhaps reversed (e.g., a further object seeming less distant than a closer one). It may be diffi- cult to determine what is in the background and what in the foreground, or how objects relate to each other spa- tially.

• “Again and again I shortly saw things crosswise, confusingly displaced against each other.” [1]

1.7.3 General Disturbances in Estimation of Distance

(=BS C.2.3.9) The subject has difficulty determining how far away he is from some object or person.

• “I couldn’t throw things in the waste-paper basket any more, I always aimed too short or too long. I had lost my feeling for the distance.” [1]

EAWE: Examination of Anomalous World Experience

• “I see things flat. … That’s why I’m reluctant to go forward. It’s as if there were a wall there and I would walk into it. There’s no depth… Until I see into things I don’t know what distance they are away.” [17]

1.8 Distorted Experiences of Space

The experience of the overall structure of space is changed or unusual in some way.

1.8.1 Diminished Perspectival Orientation

Space seems to lack its normal implicit subjective cen- tering, as if the visual world were not viewed from a dis- tinct, orienting standpoint. This may involve experiencing “isotropic” space or a “view from nowhere,” as if some- how seeing from “everywhere at once.”

• “I seemed to have lost a sense of perspective. So I copied the model from a schoolmate’s sketch, thus lending a false perspec- tive from where I sat. In the gymnasium I didn’t understand the commands, confusing left and right.” [18]

1.8.2 Loss of Topographical Orientation

Though in a familiar or comprehensible location, sub-

jects feel completely lost or disoriented.

• “There was a time when I went for a walk and I didn’t know where I was.” [13]

• “I got lost…[and felt] a general lack of orientation. I couldn’t recognize any of my surroundings, people, or places.” [13] (consider also 3.12.2, People seem unfamiliar in a strange way, and 5.1.7, Nonspecific/other derealization*)

1.8.3 Loss of Spatial Integrity or Structure

The very structure of space seems deceptive, inconsis- tent, or somehow impossible; like “living in an Escher drawing,” a space inconsistent with normal geometry. A subject might, e.g., describe walking upstairs and feeling he has arrived somewhere below, or as though a se- quence of rooms does not accord with geometric possi- bility.

1.8.4 Loss of Dimensionality

Space or the objects it contains may seem flat or two- dimensional, or otherwise condensed; three-dimensional- ity itself may seem somehow illusory.

• The subject describes objects as “mere images on canvas” or “as if they were painted on a window pane.” [21]

1.8.5 Experience of Infinite Space

Space seems somehow to go on forever or to be “enor- mous” [15].

Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

19

Univ. of California San Diego 132.239.1.231 - 3/10/2017 3:39:00 AM

Downloaded by:

• “I still saw the room. Space seemed to stretch and go on into infinity, completely empty. I felt lost, abandoned to the infini- ties of space, which in spite of my insignificance somehow threatened me.” [14]

• “…an immense space without boundary, limitless, flat; a min-

eral, lunar country, … this stretching emptiness ”

[18]

1.8.6 Figure/Ground Reversal

The subject experiences being aware of the space sur- rounding objects, rather than the objects themselves.

• “The air is still here, the air between the things in the room, but the things themselves are not there anymore.” [22]

• “When I am awake, I can look at a tree or a cat or a bird and see the air around it, sometimes it looks like water, so sometimes I paint water.” [22]

1.8.7 Affective Experience of Space*

Space itself takes on a certain affective quality that seems abnormally prominent, often with a negative tone,

of feeling threatening, frightening, or uncanny.

• “Then I felt that the autumn landscape [was pervaded] with a second Space. It was fine and invisible, hardly detectable. The second Space was dark, empty, frightening; it was difficult to say precisely what it was like.” [13]

1.9 Abnormal Intensity or Persistence of Auditory Perceptions

Sound and noises are heard as either more or less in- tense than usual, as failing to fade into the background, or as lasting much longer than usual. This may be associ- ated with increased or diminished sensitivity to audi- tory stimuli.

1.9.1 Increases in Intensity of Auditory Perceptions*

( BS C.2.4.1 ) Sounds seem louder, stronger. This may appear as an ac- tual change in the perceived intensity, or as though the sub- ject has developed a striking sensitivity to auditory stimuli.

• “I am hypersensitive to any kind of sound or noise. When I am ill, the noise is louder. All sounds irritate me.” [1]

• “I hear everything too clear and torturing, more distinct … so loud that I cannot bear it.” [1]

1.9.2 Decreases in Intensity of Auditory Perceptions*

( BS C.2.5.1 ) Sounds seem fainter or quieter. This may appear as an actual change in the perceived intensity, or as change in sensitivity to perceptions.

“I cannot hear right any more. Speech sounds so subdued, mu- sic so muffled.” [1]

20

Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

1.9.3 Heightened Awareness of Background Auditory

Sensations The subject reports unusual awareness of irrelevant background sounds that would normally diminish due to attending to other, more salient sounds.

• “Everything seems to grip my attention although I am not par- ticularly interested in anything. I am speaking to you just now, but I can hear noises going on next door. I find it difficult to shut these out, and it makes it more difficult to concentrate on what I am saying to you.” [12]

1.9.4 Recurrence or Prolongation of Auditory Stimuli

(=BS C.2.5.2) Acoustic stimuli continue to be heard, whereas they have stopped sounding minutes or hours before, perhaps similar to an echo. NB: May suggest temporal disturbances as well.

• “A subject returned to answer the door several times during a 30-minute period after the doorbell had actually rung.” [15]

• “Sometimes, when I switch off the radio what I last heard lin- gers for a while.” [1]

1.10 Disturbances Involving Veridicality (Accuracy) of Auditory Perceptions*

The subject reports having mis-heard sounds (e.g., hearing a creaking board as the subject’s name), or hear- ing things that are clearly not there. Experience can be quasi-auditory, as if midway between hearing and think- ing. NB: The focus should be on the nature of the origi- nal experience rather than on a subsequent assessment. Also, the experienced reality status of these experiences (hence the subtype) can sometimes be quite difficult to specify. If the subtype is not obvious, choose the most appropriate subtype (or subtypes, if absolutely neces- sary), recording any relevant details that might clarify the nature of the experience.

1.10.1 Auditory Illusions* The subject reports misinterpreting an external audi- tory stimulus as something else entirely, e.g., spoken words or white noise heard as something not actually inherent in the perceived sound. The experience may have a dis- tinctly “as if” rather than literal quality. This is more se- vere than simple cases of mishearing, which are brief and disappear on continued or more careful listening.

• The subject hears in the ocean waves some vaguely threatening message. (also score 5.8.2, Meaning inherent in the object itself)

• “The most disturbing of [the different voice-like experiences I’ve had] is – people talking, but for the purpose of communi-

cating or influencing me in various ways

to me whether or not any of it is an exaggeration of [what]

It’s [mostly] unclear

Sass/Pienkos/Škodlar/Stanghellini/Fuchs/

Parnas/Jones

132.239.1.231 - 3/10/2017 3:39:00 AM

Univ. of California San Diego

Downloaded by:

somebody is saying versus me ‘hallucinating.’ I don’t think it’s hallucination, generally, I just think I’m overhearing some- thing in a way that I’m interpreting it in a strange way [but] it’s unclear.” [23] (also score 3.13, People seem as if communicat- ing something special or unusual (beyond the obvious)).

1.10.2 Auditory Hallucinations *

Experiences of auditory perception that have very little or no basis in external reality. The phenomena in question have at least a quasi-real or quasi-external quality, akin, e.g., to hearing the voice of someone speaking in the room when in fact there is no one there. (The subject may not, however, feel the experience to be fully objective or whol- ly equivalent to normal perceptions.) Reporting of this item generally implies recognition, in retrospect, of the deceptive nature of the earlier experience. NB: “Voices” or other similar phenomena that do not have at least a quasi-auditory and quasi-external status (e.g. “They’re clearly thoughts, but I don’t generate them – someone else is communicating with me” [23] (consider scoring 3.7.5, Merging or fluid psychological boundaries), or “voices that feel more internal and closer to thoughts” [23] 7 ) should not be scored here nor in subtype 3.

• “One subject frequently heard the words ‘sausage and chips.’”

[24]

• “Sounds exactly like someone talking to me.” [23]

• “Sometimes I’ll just hear the word ‘no.’” [23]

1.10.3 Auditory Pseudohallucinations * ( BS C.2.4.2 )

As in hallucinations (1.10.2), the subject experiences auditory phenomena not grounded (or only minimally grounded) in any external stimulus, but here the subject is clearly aware during the experience itself that these phe- nomena have no basis in external reality.

• “From time to time I hear some vague sounds, e.g., like an animal’s sound or like a knocking hissing or humming. But I know at once or a few moments later that these sounds are not really there.” [1]

• “It [thinking] sometimes manifests as incredible noise.” [25]

1.11 Other Changes in Quality of Auditory Perceptions

The subject describes other transformations of various auditory qualities, for example, sounds may be per- ceived as lower or higher pitched than usual (like “screeching” or “squeaking”), or as “muffled” or distort- ed in some way. This may be experienced as affecting

7 Both these parenthetical examples might merit an EASE score: consider EASE 1.2, Loss of thought ipseity for both; also EASE 1.7 Perceptualization of inner speech or thought, for the second.

EAWE: Examination of Anomalous World Experience

only some subset of sounds (e.g., certain voices) or all sounds. If this seems primarily a matter of understand- ing linguistic communication, see Domain 4.

1.12 Problems Localizing Sounds

The subject has difficulties determining where sounds might be originating, feels confusion as to whether on the right or left, in front or behind, perhaps especially when the actual source of the sound cannot be seen. NB:

Do not score if only related to auditory hallucinations or pseudohallucinations.

• “…I seem to get a little mixed up about where sounds are com- ing from….several times I thought someone was shouting through the window when it was really the wireless at the front of the house.” [12]

1.13 Disturbances of Other Senses* (=BS C.2.6)

The subject experiences tactile (touch), gustatory (taste), or olfactory (smell) sensations as different from usual.

1.13.1 Tactile Disturbance * ( =BS C.2.6.3 )

Objects feel somehow different or changed when touched. This may also include abnormal persistence of tactile sen- sations that are no longer occurring, or subject may feel as though touching or being touched by something that is not there.

• “The feeling of touch has become most unpleasant. When I touch wood…wool or paper, I feel a burning sensation run through all my limbs.” [14]

• “When I touch things or my own body, it feels different from before. When I knit, the knitting needles sometimes feel pecu- liarly different, somehow sticky. And soft wool, too, feels dif- ferent, like straw.” [1]

1.13.2 Gustatory Disturbance * ( =BS C.2.6.2 )

Objects taste different to the subject. This item may in- clude an overall shift in the taste, more or less intense, or more or less pleasant. Subject may also experience tastes unrelated to any stimulus, or a fragmentation of gusta- tory experience, e.g., tasting separate ingredients.

• “All my senses enjoy things more. Taste is different and much more intense than before.” [14]

• “I could not taste anything, everything was tasteless and insip- id.” [1]

• “I cannot taste the soup but only its ingredients. Tasting the whole soup requires a reconstruction.” [26]

1.13.3 Olfactory Disturbance * ( =BS C.2.6.1 )

Subjective change in experience of smells, as qualitative- ly different, more or less intense, or more or less pleasant.

Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

21

Univ. of California San Diego 132.239.1.231 - 3/10/2017 3:39:00 AM

Downloaded by:

Subject may also experience smells unrelated to any stim- ulus.

• “For about half a year, I couldn’t smell any more, for instance,

I didn’t smell the burned milk and was not able to differentiate vanilla and coffee.” [1]

1.14 Synesthesia or Abnormal Concomitant

Perception*

An experience in one sensory modality seems automat- ically to elicit an associated response in a different modal- ity. Can be experienced as pleasant or as dysphoric.

• “With every word spoken to me or near me, with every slight noise, I feel a blow on my head, producing a certain pain. …like an intermittent pulling in my head, probably linked with a rending of part of the skull-bone.” [14] (consider also 1.9.1, In- creases in intensity of auditory perception*)

1.15 Splitting-Off or Isolation of Sensory Perceptions

Sensory phenomena seem independent, separated from their source, as when a person’s speech, or an an- imal’s sound, seems somehow divorced from the per- son or animal from which it is nevertheless seen, or known, to emanate. This may occur with all sensory modalities, but is most commonly found with auditory perception.

• “A bird chirrups in the garden. I hear it and know that it is chir- ruping but that it is a bird and that it is chirruping are two things which are poles apart.” [14]

1.16 Disturbances in Recognizing or Identifying an

Object of Perception (=BS C.2.7)

The subject feels unable (or significantly delayed in his ability) to recognize or identify an object of visual or au- ditory perception (which is nevertheless clearly seen or heard), e.g., to comprehend that he is seeing a rose or to recognize an acquaintance, or a sound as that of a car braking or accelerating.

• “Things I clearly see in front of me don’t pass to my mind and

I remain insecure.” [14]

• “Sometimes, I pass people and look straight in their faces, but

only when I have already passed by, I recognize that they are familiar, that I know them quite well.” [14]

1.17 Loss of Boundaries with, or Demarcation from,

the Physical World (=BS B.3.4.1, EASE 4.5)

The subject has a sense of being unable to determine where her body ends and the outside world begins. A physical intermingling whereby external objects seem to be inside or merged with the subject’s body, or the re- verse. NB: If loss of boundaries concerns other persons,

22 Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

see Domain 3. If experience involves less a sense of fu- sion than of mystic union, score 5.15.1, Mystic union with the world* (though these need not be mutually ex- clusive).

• “As I was looking at the packet of cigarettes in my hand, I sud- denly wasn’t sure whether the packet was part of my body or not.” [14]

• “While I was riding the bike, I suddenly felt a kind of melting into my bike, as if the bike and I had become one.” [unpub- lished data]

2 Time and Events

General Description. The 6 items in Domain 2 refer to various ways in which actions, events, sequences, or the flow of time can be experienced in anomalous fashion. Here, the focus is on temporal and dynamic aspects of the world, those involving movement, memory, anticipation, and change over time. Note that two or more of these as- pects can often occur together, and that experiences of déjà vu or jamais vu are included in Domain 5: Atmo- sphere.

2.1 Time or Movements Appear to Change Speed (BS C.2.12)

Distortion of the in-the-moment experience of time or movements, with these either accelerated or slowed down. Typically these disturbances are unrelated to the per- son’s activity level and should not occur only during pe- riods of waiting or of exciting activity. [1]

2.1.1 Time or Movements Seem Speeded Up*

• “It seems to me that everything was going much faster than be- fore. The nurses and the patients were moving … more quickly than is usual. When the doctor spoke it sounded fast, loud and at a higher pitch.” (schizophrenia patient after insulin coma) [27] (also score 1.9.1, Increases in intensity of auditory perception*, and 1.11, Other changes in quality of auditory perception)

• “Birds pecking much faster than realistically possible.” [28]

• “Time went by very quick.” [28]

2.1.2 Time or Movements Seem Slowed Down*

• “Night seemed to be longer.” [15]

• “Longer slower time.” [15]

• “Time dilated.” [15]

2.1.3 Time or Movements Seem ( Somehow ) Both

Speeded Up and Slowed Down

• “Time slower, faster, timeless.” [28]

• “Mouth movement and speech of other out of synchronizing:

one faster and the other slower.” [28]

Sass/Pienkos/Škodlar/Stanghellini/Fuchs/

Parnas/Jones

132.239.1.231 - 3/10/2017 3:39:00 AM

Univ. of California San Diego

Downloaded by:

2.2 Discrepancy between Internal and External Time*

(BS C.2.12, EASE 1.14.1)

The subject reports sensing that his own internal time clock is running at a different speed from the rest of the world. This may be experienced as a shift in internal time, external time, or both; what is crucial is the report- ed discrepancy.

2.2.1 Internal Time Seems Slower than World Time*

The subject experiences her own actions, thoughts, or emotions as immobile or very slow, while people and events move at a normal or faster pace.

• “Outside things still go on, the fruits on the trees move this way and that. The others walk to and fro in the room, but time does not flow for me … What does the outside world have to do with me? I only bump up against time.” [29]

• “I feel like a slow, big giant.” [28]

2.2.2 Internal Time Seems Faster than World Time*

The subject feels he is operating, or thinking, at a pace

faster than that of the external world.

• “I felt I was moving normally and everyone was moving slow- ly.” [28]

2.3 Disruption of Dynamic Organization of Time

(EASE 1.14.2)

The subject feels that the normal flow or passage of time cannot be taken for granted as a coherent but dy- namic background for experience. There is disruption of the lived and living unity or synthesis whereby the expe- rienced present moment incorporates, within itself, both the immediate past (what the philosopher Husserl [6] terms “retention” or “primary remembrance”) and the anticipated, impending future (Husserl’s “proten- tion”) 8 .

2.3.1 Time Feels as though Completely Stopped,

Static, Infinite, Disappeared The subject may experience time as having halted or come to a standstill. It can seem as if it is always the same moment; as if the present is all there is; as if time is frozen or immobile, has ceased to flow or even to exist in any meaningful way; or perhaps as if a short period of time has gone on for a much longer time than was actually the

8 For discussion see James [7] on “specious present” and “duration block.” Also, see Husserl [6] on the “temporal halo” that, in normal temporal experi- ence, surrounds the “now point”; this refers to the intertwining or interfusion of “retention” and “protention” with the “primal impression” of the “actual now of consciousness.”

EAWE: Examination of Anomalous World Experience

case. Can be associated with feelings of unusual signifi- cance, also with bewilderment or perplexity about seem- ingly obvious sequences of events.

• “It feels as if it is always the same moment … like a timeless void.” [14] (consider also 5.17.1, Emptiness, numbness, indif- ference, lack of spontaneous response to the world*)

• “Thought stood still, yes everything stood still, as if time had ceased to exist.” [29]

• “I continue to live now in eternity, there are no more hours or days or nights.” [29]

I suddenly had the feeling as if

I had been standing there for about two hours…checked my watch…. I had been standing there just for a couple of sec- onds.” [1]

• “I stopped to light a cigarette

2.3.2 Time as Disjointed or Fragmented (BS C.2.10)

A loss of normal, continuous temporal flow; instead, moments seem disconnected, disjointed, or out of sequence, perhaps like a collection of unrelated snapshots or now- moments, or as if in a strobe light. The flow of events feels utterly random or arbitrary, without cause, reason, or meaningful continuity. Music, for example, may be expe- rienced as a succession of independent notes, unrelated, and lacking unity. Observed movements may be experi- enced as choppy and nonsensical, as if devoid of orienting direction or organizing purpose, sometimes like mere agitation.

• “The hand [of the clock] is constantly different…now it is here, then it jumps so to speak and turns. Isn’t this a new hand every time?” [29, 30]

• “While watching TV it becomes even stranger. Though I can see every scene, I don’t understand the plot. Every scene jumps to the next, there is no connection.” [31]

• “The course of time is strange, too. Time splits up and doesn’t run forward anymore. There arise uncountable disparate now, now, now, all crazy and without rule or order.” [31]

2.3.3 Disorientation in Time

The subject experiences difficulty or confusion situat- ing events within the passage of time, or regarding the no- tion of time itself.

• “I was asking continuously when my mother would arrive.” [unpublished data]

• “I cannot remember time.” [unpublished data]

• “I looked at a clock and it didn’t mean anything.” [28]

• “It was all like a story. Middle of day seemed like night.” [28]

2.3.4 Feeling Limited to or Isolated within the

Present Moment Difficulties representing, conceiving of, or feeling con- nected to one’s own past or future, because one’s experience feels restricted to the present. NB: See also 2.4.4, Proten-

Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

23

Univ. of California San Diego 132.239.1.231 - 3/10/2017 3:39:00 AM

Downloaded by:

tion (future directedness) collapses, and various subtypes of 2.6, Disturbed experience of memories or of the past.

• “From moment to moment, various “selves” arise and disap- pear entirely at random. There is no connection between my present ego and the one before.” [32]

• “It’s all collapsed into the present so I guess I don’t see a future any more than I see a past. It just seems to be an omnipresent pure present presence, I guess.” [unpublished data]

2.3.5 Various Bizarre Experiences of Time

Including a general sense of strangeness, or more spe- cific disturbances, such as time going backward, feeling reduplicated, looping or repeating itself, or of events seeming oddly delayed, of controlling time, or of existing in multiple temporal dimensions. (Interviewer should re- cord the example.) NB: Feelings of reduplication, looping, or repeating are distinct from déjà vu (5.5, Déjà vu experi- ences), which describes a general sense of having experi- enced things before, and also from recurrence of stimuli or objects (1.1.3, Recurrence or prolongation of visual stimuli, and 1.9.4, Recurrence or prolongation of auditory stimuli); here, whole segments of time or sequences of ex- periences or events seem to be repeating themselves.

• “Time is somewhat changed. It isn’t supposed to be the way it is. I don’t know in what way.” [33]

• “I thought I was controlling time. I thought I was here and in a different dimension at the same time.” [33]

• “Time going back to same moment over and over.” [34]

• “…not only time repeated itself again…. A foreign time sprang up. Everything was confused, pell-mell, and I felt contracted in myself.” [29]

2.4 Disturbed Anticipation

The normal sense of imminence, of directedness toward an anticipated immediate future, is somehow altered or disturbed. The emphasis here seems to be on distortion of the normal protentional and/or retentional aspects of temporal experience [6, 31].

2.4.1 Perpetual Anticipation

The feeling that something very important (though perhaps unidentifiable) is always about to happen, of “something imminent,” of “living in an eternal and preg- nant ‘now’” or “a state of suspense” [21, 28] (also called the ante festum experience [35] or the trema [36]). NB:

Unlike 5.14, Revelatory or pseudorevelatory (apopha- nous) mood, in which objects in the world or the experi- ence of the world as a whole takes on a feeling of strange- ness or specialness, perpetual anticipation has a specifi- cally temporal focus (imminence, an impending quality).

24 Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

• “Then everything seemed to stop, to wait, to hold its breath, in a state of extreme tension….Something seemed about to occur, some extraordinary catastrophe.” [18]

2.4.2 Constant Surprise due to the Inability to

Anticipate Future Events The subject experiences pervasive sense of novelty, sur- prise, or anxiety regarding events that, normally, would not elicit such a response (since they would be expected), as if she experienced no continuity with the past, no “retro- continuity,” but without loss of memory in the usual sense [37]. The subject might describe it as though the world is constantly “starting anew.” NB: Unlike 5.6, Ja- mais vu experiences, this need not involve a distinct, un- canny sense that one is encountering something that should be familiar yet is not; also, it typically involves more of a continuous, ongoing experience, in contrast to the relatively discrete experiences typical of jamais vu.

• “And everything was new for me, it was all new for me.” [37]

• Every morning, “always everything again [seemed] completely different.” [37]

2.4.3 Feeling that “Anything Could Happen”

With related diminished emotional response. This is not just the common feeling that the future is unknown, but that all possible unfolding events seem equally likely or un- likely, as if the usual continuity or predictability of the world were absent and almost anything could happen next. Hence, normal anticipation toward imminent events and any related emotional response (e.g., surprise or anticipa- tory pleasure) are impossible. The subject may note the absence of “anticipatory nervousness” or “anxiety.” This may include the sense or belief that laws of nature, com- mon sense, or a coherent flow or developing of events no longer apply; if so, also score 6.2.2, Conceptual freedom/ anything goes.

• “On the one hand there’s this weird feeling that anything could be around the corner – monsters, the end of the world – and yet it’s all still like ‘so what.’ There’s no feelings of anxiety like one might expect. I notice this, and often wonder why these possibilities that would normally frighten people have no im- pact on me.” [unpublished data] (consider also 5.17.1, Empti- ness, numbness, indifference, lack of spontaneous response to the world)

2.4.4 Protention ( Future Directedness ) Collapses

The subject reports a loss of immediate anticipation: a feeling that it is impossible to move naturally into the im- minent future. (Here the issue concerns the sense of time flowing dynamically into the next instant rather than ex-

Sass/Pienkos/Škodlar/Stanghellini/Fuchs/

Parnas/Jones

132.239.1.231 - 3/10/2017 3:39:00 AM

Univ. of California San Diego

Downloaded by:

pectations concerning an imagined future time period, as in 2.5.1, Future seems nonexistent*.) There may also be a sense of being stuck in the present (see 2.3.4, Feeling lim- ited to or isolated within the present moment), or even being drawn or sucked into the past (see item 2.6.6, Intru- siveness of the past*).

• “Everything around me is motionless and congealed…I see the future as only a repetition of the past.” [38]

2.5 Disturbed Awareness of the Expected Future*

The imagined or conceived future (as distinct from the immediate/imminent future of protention) is experi- enced as irrelevant or nonexistent, as highly threatening, or as abnormally known or otherwise revealed in ad- vance.

2.5.1 Future Seems Nonexistent*

The subject is unable to think about, imagine, or other- wise conceive the possibility of a future time period (as dis- tinct from lacking the immediate sense of moving toward

or into the next moment, as in 2.4.4, Protention [future directedness] collapses). This may or may not be experi- enced as distressing to the subject.

• “I cannot see the future, just as if there were none. I think ev- erything is going to stop now and tomorrow there will be noth- ing at all.” [14]

• “[I feel] really disconnected from anything that might happen in the future….even if I know what I’m doing, I can’t quite per- sonalize it, like for me…will I be eating dinner? It has to be specific in my mind for me to feel like it’s real. And because I can’t predict those kind of things, I just don’t feel connected to it.” [unpublished data]

• “Sometimes it seems … that there’s not a future for me. I don’t know how to explain it. Kinda like, where it’s gonna go on, but I’m gonna stop.” [unpublished data]

2.5.2 Future Seems Unimportant or Irrelevant*

Future events seem to lack any significance or emotion- al charge. The subject may report feeling “indifferent” or “apathetic” toward expected future events.

2.5.3 Future Seems Threatening*

The subject describes experiencing the future as threat- ening or overwhelming, often to the point of being a dan- ger to his very existence. He may describe various behav- iors or techniques used to avoid thinking of the future.

9 This concerns what Husserl [6] termed “secondary remembrance” or “recollection,” as opposed to “primary remembrance” or “retention.”

EAWE: Examination of Anomalous World Experience

• The subject reports feeling the future is full of “deadlines by which I would have to do things or everything would stop.” [unpublished data]

• “The future was blocked [for the patient] by the conviction of

a destructive and terrifying event [his execution]. This convic- tion completely dominated his outlook.” [29]

2.5.4 Premonitions *

The subject describes somehow knowing what was go- ing to happen before it happened. This may range from a hint or feeling of knowing events that are going to occur, to a sense of knowing exact details about future events.

• “I felt something good was going happen to me.” [28]

2.6 Disturbed Experience of Memories or of the Past

The remembered past is felt to be changed in some way, whether overly cut off, vague or obscure, disappeared, overly sped up or slowed down, disjointed, or intrusive 9 .

2.6.1 Past Seems Cut Off*

The subject feels dissociated from past memories, as if the past were utterly disconnected from, or unrelated to, the present moment (existing somehow like a “time before time”), or as if past events had never really happened to oneself (that they were merely imagined or dreamed, for example).

• “I was cut off from my own past, as if it had never been like that, so full of shadows…as if life had started just now…” [14]

• “[The past feels] like something that one has read in a book or

a novel but never actually experienced oneself.” [unpublished data]

2.6.2 Past Seems Vague or Obscure*

Therefore, it is difficult to remember. The subject may

describe past as though “lost in a fog.”

2.6.3 Past Disappears or Seems Nonexistent*

The subject cannot remember past experiences at all

and may feel the past never actually occurred.

• “Sometimes [the past] just doesn’t seem to exist, so a memory, like my therapist can tell me something has happened, I’ll think ok that exists because you’re telling me about it right now, not because it actually happened….Sometimes I think that I never was a child, never had a childhood, never had a past.” [unpub- lished data]

2.6.4 Past Seems Accelerated*

In retrospect, past memories seem somehow condensed, as though a sequence of events of long duration had oc-

Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

25

Univ. of California San Diego 132.239.1.231 - 3/10/2017 3:39:00 AM

Downloaded by:

curred over a very short period of time, or the events were somehow speeded up.

• “Months and years fly by with excessive speed. [One] subject felt a past of twenty-nine years had lasted only four years at most and the smaller time-spans within this period were cor- respondingly shortened.” [14]

2.6.5 Past Seems Slower*

The subject feels that past memories are drawn out, or that events occurred over a much longer period of time than was really the case.

• “My own memory gives me the impression that this time- span, 3–4 months by ordinary reckoning, was an immensely long time for me, as if every night had the length of centuries.”

[14]

2.6.6 Intrusiveness of the Past*

The subject’s present, and even his future, feels some- how overwhelmed or overcome by his past, as though he

can no longer think of anything else, or nothing else seems real by comparison.

• “There is no more present, only a backward reference to the past; the future goes on shrinking – the past is so intrusive, it envelops me, it pulls me back.” [14]

2.6.7 Erosion of Distinction between Past and

Present* The subject is uncertain about whether she is remem- bering something from the past or actually living it in the

present moment. There can be a sense of being over- whelmed by the past, but here (unlike 2.6.6, Intrusive- ness of the past*, or 5.5, Déjà vu experiences), there seems to be some confusion regarding past versus pres- ent.

• “Time seemed like I was back in the past, not today’s time.”

[15]

2.6.8 Past Seems Disjointed

Past events appear in retrospect as disconnected, dis- jointed, or out of sequence rather than a sensible series of events.

“I feel as if I’ve lost the continuity linking the events in my past. Instead of a series of events linked by continuity, my past just seems like disconnected fragments.” [22]

“…then the past turned round…everything got intermingled but in no comprehensible way; everything shrank, fell together, packed up.” [14]

“When the visit is over, it could very well have happened yes- terday. I can no longer arrange it, in order to know where it belongs.” [29]

 

26

Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

3 Other Persons

General Description. The 14 items in Domain 3 refer to anomalous experiences of other human beings or the in- terpersonal world. The focus here is on experiences of social interaction, empathy or lack thereof, interpersonal ego boundaries, and the general look, feel, or influence of other persons. Experiences focusing on linguistic com- munication (words, sentences, or discourse) are included in Domain 4: Language.

3.1 Lack of Social Understanding or Interpersonal Attunement (Hypoattunement) (BS A.7.1, EASE 2.12)

A feeling of extreme distance and detachment from others, involving the sense that one’s movements, ges- tures, or speech are somehow not coordinated with oth- er people, of lacking nonverbal attunement and espe- cially social common sense (difficulty understanding or adhering to “rules of the game”). This may be experi- enced as a loss of spontaneous engagement or reso- nance with the social world, and/or as a self-conscious (hyperreflexive) awareness of or alienation from one’s own behavior or experience. This goes beyond the sense of being “out of sync” with others due to common forms of social anxiety or depression, where basic social com- mon sense is maintained. It is not restricted to specific persons or situations and involves a widespread (though not necessarily constant) sense of estrangement from nearly everyone.

3.1.1 Loss of Social Common Sense

Sense of lacking natural grasp or spontaneous under- standing of other people’s behavior or the social encounter.

• “People move weirdly about…make gestures, movements without sense.” [30]

• “I simply cannot grasp what the others do.” [39]

3.1.2 Bodily/Proprioceptive Loss of Attunement

The subject describes having a largely physical sense of

being awkward and out of sync with other people.

• “My cousin just had a baby, and I feel really happy, but I have to think about how I’m showing it… I don’t have that kind of automatic reaction to things like other people do.” [unpub- lished data]

• “It’s sometimes difficult for me to move and do things natu- rally. So when I take a drink from my glass, and I’m having din- ner with people, I always have to pay attention to…who’s pick- ing up their glass after other people.” [unpublished data]

Sass/Pienkos/Škodlar/Stanghellini/Fuchs/

Parnas/Jones

132.239.1.231 - 3/10/2017 3:39:00 AM

Univ. of California San Diego

Downloaded by:

3.1.3 Specific Difficulty Understanding Nonverbal

Communication The subject has difficulty understanding nonverbal communications or is aware of misreading gestures or fa- cial expressions of others.

• “Other people’s gestures often seem odd to me… because I’m really noticing the movements.” [unpublished data]

• “I would really be overly attentive or critical or curious of body language. Like…if I happened to be walking toward someone and they were moving away, I might take [it to mean that] they were [intentionally] moving away from me.” [unpublished data]

3.2 Sense of Remoteness from Others*

(EASE 2.4.1)

Feeling of being separate, apart, cut off, or profound- ly out of touch with other people, of being uninvolved and observing others from a distance, like a detached spectator, without feeling or spontaneous emotional connection. NB: This may or may not be accompanied by a sense of diminished interpersonal attunement (3.1 Lack of social understanding or interpersonal attune- ment (Hypoattunement)) involving awkwardness or failure to grasp the meaning of interpersonal situa- tions.

• “I cut myself off from other people and became shut up in my- self.” [40]

• “There is a pane of glass between me and mankind.” [22]

• “A wall of void isolated me from everybody.” [21]

3.3 Alienated/Intellectual Strategies for Understanding

Others

The subject relies on detached observation or intellec- tualized, rule-based methods for understanding and re- sponding to others, due to a sense of being unable to im- mediately grasp commonplace social interactions.

3.3.1 Alienated Scrutinizing of Others’ Behavior

The subject is aware of observing others in order to un- derstand social situations or figure out how to live (e.g., by copying others or discovering the formula by which they

must be behaving; if the latter, also score 3.3.2, Algorith- mic approach to social understanding/interaction). This may involve a sense of engaging in “ethological” observa- tion of other persons or “scientific” analysis of “intelli- gent” systems or machines.

• “I am like an emperor in his pyramid. I am not involved in the world, merely observing it from outside to understand its secret workings.” [41]

• “The others know the rules; I have to study them.” [41]

EAWE: Examination of Anomalous World Experience

• “When I was a child, I used to watch others to see what was the moment to be happy or to be sad.” [39]

3.3.2 Algorithmic Approach to Social

Understanding/Interaction The subject attempts to understand or respond to social encounters by discovering or creating an explicit formula, algorithm, or set of rules. This may seem driven by theo- retical curiosity or by an attempt to cope, and may be felt to be successful or unsuccessful.

• “Should I make the algorithms to talk with him?” [39]

• “People have a system. I try to understand it. But then I don’t understand anything.” [39]

3.4 Sense of Inferiority, Criticism, or Mistrust in Relation to Others*

A feeling of extreme difficulty in establishing rapport/ mutuality or feeling safe with others due to a sense of in- feriority or experience of hostility from others.

3.4.1 Feelings of Self-Consciousness, Self-Criticism*

Usually with sense of inferiority in relation to others or

hyperawareness of one’s personal defects or awkwardness in interaction.

• The subject finds herself asking, “Why do I have to think so hard about what little things I’m doing?” [unpublished data]

• “Am I doing the right thing, am I doing what other people would think is acceptable?” [unpublished data]

3.4.2 Feelings of Social Paranoia or Social Anxiety*

Feeling as though others are unusually focused on one- self, whether commenting, judging, or simply staring in a way that makes the subject feel self-conscious, guilty, ashamed, or anxious. The subject may feel especially vul- nerable to or destabilized by the critical gaze or attitudes of other people. NB: This item can be similar to, or occur alongside, 5.12, All-inclusive self-consciousness/onto- logical “paranoia” or 6.10, Feelings of centrality, and may be queried in conjunction with these.

• “I was convinced that…everyone who saw me instantly knew I had some sort of social handicap…as if everybody who met me pretended to treat me normally and then laughed at me behind my back once I’d gone.” [42]

• “I always feel like I walk into a room, people are staring, talking about me, they can know what I’m thinking. They know how stupid I’ve been in the past.” [unpublished data] (consider also 6.10, Feeling of centrality)

3.4.3 Pervasive Mistrust of Others*

The subject has a general sense that others are untrust- worthy or intending some kind of harm. This may or may

Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

27

Univ. of California San Diego 132.239.1.231 - 3/10/2017 3:39:00 AM

Downloaded by:

not include sense of paranoia (3.4.2) that others are un- usually focused on oneself.

• “Getting in touch with others scares me. They can harm me.”

[43]

3.5 Torment or Distress due to Generalized Social

Insecurity (BS A.8.2)

Very presence of other people feels burdensome, acute- ly stressful, even unbearable. Typically involves a basic ontological vulnerability or insecurity more basic than shame, guilt, or sense of social inferiority – as if one’s very self were unstable and vulnerable to being destroyed or annihilated by others. This may involve distressing affect or emotion and/or uncanny bodily sensations evoked by interpersonal contacts.

• “Although I like company, conversations have recently be- come exhausting, stressful. Even the talking of others affects me.” [1]

• “Being with people provokes an emotional crisis in me.” [39]

• “When people get too close to me I feel nervous.” [39]

3.6 Interference by Voices*

The subject feels unable to participate normally in so- cial situations due to experiencing voices (hallucinated or imagined) that are distracting or disorganizing.

• “Dealing with the three [voices] together…the sound would be just tremendous. I couldn’t think …I couldn’t concentrate, I couldn’t do certain tasks because they’d be all talking.” [unpub- lished data]

3.7 Disturbance of Self-Other Demarcation

(= EASE 4.1)

The subject feels that the basic sense of independence or separateness of self and other persons has broken down or become much more fluid than normal. This may involve feelings of unusual empathy, openness, control, fusion, or confusion between self and oth- ers – whether experienced physically, psychologically, or concerning identity.

3.7.1 Hyperattunement The subject may feel as though he can “read” or under- stand the minds of others in a direct manner, as if having immediate access to the other’s consciousness, e.g., when the other person is silent, or is understood to express ideas inconsistent with his actual words (excluding normal irony, etc.).

“I suffer from acute empathy and identification.” [43]

28

Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

• “I think sometimes somebody is saying something because I think they’re thinking it, and I think they’ve actually said it out loud.” [unpublished data]

3.7.2 Unusual Influence over Others

The subject feels able to control others’ thoughts, feel- ings, or actions in some immediate or nonnatural way (not merely via normal forms of influence).

• “The people that I look at, I make them have my own thoughts.”

[44]

• “My radar beam was a source of delight to me… I was able to summon it at will or to extinguish it…move it into my eyes, stare angrily at my enemy and he would become pale, fright- ened, and usually leave.” [45]

• “Whenever I enter a room, I spread my energy all around and people become anxious and restless.” [unpublished data]

3.7.3 Pathological Openness

The subject feels as though her thoughts, feelings, or

soul/self are somehow exposed, and that others some- how enter or can directly know the contents of her mind.

• “My mind is too open. There is no filter. Everything goes in.” [unpublished data]

• “[It felt like] my head was open and they could put thoughts in, [and so] they could probably check what’s in it as well.” [un- published data]

3.7.4 Experiences of Being Controlled

The subject feels that his/her thoughts, feelings, or ac- tions are controlled by others (in some special way, as in 3.7.2 Unusual influence over others).

• “Imposing thoughts coming into my head, and that’s always at the back of my head, near the brain stem actually, and I’m be- ing taken over by some foreign sense to do things that I don’t want to do.” [unpublished data]

• “…neighbours could read her mind, make her take the wrong turning in the street to prevent her seeing men and make her think violent thoughts because they sensed she liked men.” [33] (also score 3.7.3, Pathological openness)

• “[Sometimes I think that] there’s this other mind, and I am re- ally part of this other mind, and they control me, they control the entire universe.” [unpublished data]

3.7.5 Merging or Fluid Psychological Boundaries

The subject feels her mind to be interpenetrated, mixed-up, or invaded, as if experiencing the thoughts, feelings, or memories of other people, or unsure about who possesses which experience – usually unpleasant or anxiety-provoking, often with uncertainty or confusion regarding psychological boundaries.

Sass/Pienkos/Škodlar/Stanghellini/Fuchs/

Parnas/Jones

132.239.1.231 - 3/10/2017 3:39:00 AM

Univ. of California San Diego

Downloaded by:

• “Gradually I can no longer distinguish how much of myself is in me, and how much is already in others.” [22]

• “I feel the mental states of others and I can no longer find my- self.” [43]

• “When I’m actually attempting to visually engage people … there doesn’t seem to be any space between us, mentally. It’s really difficult to distinguish their thoughts and speech from my thoughts and my speech, and I feel like I’m not sure when I’m just thinking something, if they’re hearing it.” [unpub- lished data]

3.7.6 Universal Merging with Others*

The subject feels as though people simply do not exist as discrete individuals, but that all people are somehow merged, perhaps as a kind of hive mind or unified con- sciousness.

• “I feel immersed in the human flood.” [43] (translation altered)

3.7.7 Uncertain Personal Identity/Attitudes*

The subject feels confusion about her identity or atti- tudes or preferences when in the presence of other people, as if unable to resist conforming or unable to maintain an autonomous separate perspective. The issue here concerns the authenticity of, or confidence in, one’s own opinions or attitudes (not the very sense of living or possessing one’s own experiences).

• “I have observed already for a long time, how I change in the presence of other people. I start behaving as the other behaves, talking as the other talks etc. I wonder then what is my real identity, if I constantly change it.” [unpublished data]

• “If I’m with my mom I act more like my mom, if I’m with my sister I feel more like my sister.” [unpublished data]

3.7.8 Uncertain Physical Boundaries (EASE 4.3)

The subject feels confusion about the boundaries or dif- ferentiation of physical traits or body parts of self and of other persons.

• “I always try to avoid physical contacts since when people even touch me I feel they penetrate inside me.” [43]

• “Other people’s bodies intermingle with her.” [46]

• One patient referred to other people in the ward as “All mov- ing, rushing inside my head… They’re swinging round, push- ing the head out.” [47]

3.7.9 Experience of Being Imitated (=BS C.1.18)

The subject feels as though other people are imitating his movements and actions or perhaps making fun of them by acting them out in a mocking way. The imita- tion is felt to have an uncanny, strange, or out-of-the- ordinary quality. NB: In contrast to 5.13.4, Pseudomove-

EAWE: Examination of Anomalous World Experience

ments of objects/persons, here the subject has the sense that people are intentionally mimicking or mirroring him.

• “When I was standing on the platform, I saw this guy on the opposite platform, and I had the impression, he was doing ex- actly the same as I did, was somehow copying me. It was as if he were my mirror image.” [1]

• “As she saw a group of passengers getting off the bus she had a feeling that they were performing some sort of a parody of her actual state.” [2]

3.8 Difficulties with the Gaze

Feelings of difficulty or discomfort with eye contact as such. The subject particularly notices eye contact or the gaze, feels intrigued or unnerved by it, and may be prone to analyze it.

3.8.1 Intrusiveness of the Gaze of the Other

The gaze of the other person is perceived as piercing and intrusive, perhaps difficult to bear. The subject may

report looking down or away in order not to lose her- self.

• “I feel gazes of other people as piercing, as if stabbing into me.” [unpublished data]

• “When I look at the eyes of the other, I perceive them as very strong, almost impossible to bear.” [unpublished data]

3.8.2 Feeling of Exposure through One’s Own Eyes

( EASE 4.5 )

The subject feels caught or exposed because his inner life is directly revealed to others who look into his eyes, giving others immediate access to his thoughts or emotions. This sometimes has a somatic/physical quality, as if one’s eyes could be physically entered.

• “When someone looks at me, I feel exposed. I feel embarrassed that the other can literally ‘see’ my interiority.” [unpublished data]

3.8.3 Intrusiveness of One’s Own Gaze

The subject feels her own gaze to be penetrating and disturbing for other people, as if conveying something bad or unpleasant, perhaps negative “energy,” through her eyes.

• “I have a constant feeling that I spread bad energy through my eyes.” [unpublished data]

• “Sometimes I feel that everyone gets irritated and restless when I make eye contact.” [unpublished data]

• “I worry that when I look at people I may be injuring them somehow.” [unpublished data]

Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

29

Univ. of California San Diego 132.239.1.231 - 3/10/2017 3:39:00 AM

Downloaded by:

3.8.4 Dehumanization of the Eyes of Others

There may be a compelling sense when looking in oth- ers’ eyes that they are not really alive or conscious, and/or have a disconcertingly object-like or material quality. Eyes or eyeballs of other person (or one’s own, seen in mirror) may seem, e.g., like “strange marbles” or as having a dis- concertingly “glassy” or “metallic” sheen.

3.8.5 Eyes as Cosmic Portals

The subject describes uncanny sense of the eyes of oth- er people (or one’s own, seen in the mirror) as opening onto “mystic,” “cosmic,” or “spatial” dimensions.

3.8.6 Unspecific Uneasiness with the Gaze

The subject feels unspecific uneasiness and anxiety while making eye contact with another person, but is unable to specify why. He prefers not to look at the eyes of others.

• “When I make an eye contact with someone I feel uneasy. I cannot describe exactly why, but I feel like escaping or at least looking away.” [unpublished data]

• “When I look someone straight in the eyes I feel strange vibra- tions inside.” [43]

• “I have never been able to stand the gazes of others.” [37]

3.9 Depersonalization of Others

Other people experienced not as living, breathing hu- man beings, but rather as dead, unreal, illusory, or me- chanical in some way. More than one subtype can be chosen. NB: If other objects or situations are included in this feeling, also score appropriate subtype of 5.1, Dere- alization of the world.

3.9.1 People Seem Dead*

Living people have a specifically corpse-like quality. This involves a strong feeling of the deadness of others and may

or may not involve a conviction that they must in fact be dead (as in Cotard delusion).

• “People looked strange as if they were dead.” [15]

• “Things were bad. As if I was on the Underground. It was like a dream. All I could see were people in a car. They looked like ghosts, statues, monuments, as if cremated.” [33] (also score 5.1.3, Deanimation*)

3.9.2 People Seem Unreal/False/Illusory

The subject perceives other people as if they were artifi- cial, oddly fraudulent, or like copies of themselves (though

not disguised; see 3.12.3, People seem disguised*, below). Or else they may seem as though they are not part of nor- mal objective/intersubjective reality or are otherwise sub- jectivized, e.g., seeming mythical, fictional, or imaginary.

30 Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

• “People appear to me as diminished in size and made out of paper or cotton, like small paper mâché chess pieces.” [unpub- lished data]

3.9.3 People Seem Mechanical The subject perceives other people as if they were ma- chines and thus devoid of vitality, subjectivity, or inner life.

• “She seems… a manikin moved by a mechanism, talking like an automaton… movements were deprived of emotion and feeling.” [18]

3.10 Persons Dominated by a Single Characteristic

The character or appearance of another person seems utterly defined by or limited to a particular characteristic, as if the person were inseparable from, completely summed up or revealed by, e.g., shape of nose, way of walking, typical gesture, or comment.

• “Whenever I’m around people, I look at the way they’ve posi- tioned their feet: are they turned in or out or perfectly straight. The positioning of their feet tells me who they are and what they believe in.” [unpublished data]

• “The colors of the clothing people wear tells me a tremendous amount about their values and what they believe in.” [unpub- lished data]

3.11 Heightened Intensity, Aliveness, or Reality of

Others*

People experienced as somehow more intense, alive, or real than usual, in a way that seems abnormal, uncanny, or not quite human.

• One informant reported experiencing others as “gods, manifes- tations (faces) of a single god [or] superhumanly powerful”; she described “increases in metaphysical dynamism, universal ani- mism, emotional resonance, human and/or divine purposive- ness.” [48]

3.12 Changes in Quality or Tone of Others’

Appearance

The way people look, or the way their appearance is experienced, is changed in some strange or uncanny fashion.

3.12.1 People Seem Familiar in a Strange Way People unknown to the subject seem familiar in a strange or uncanny fashion. NB: If nonhuman objects, situations, or events are also included in this feeling, score also 5.5, Déjà vu experiences.

• “Patient reported that she couldn’t help noticing that she saw faces in the clinic which she has seen at home a few weeks be- fore.” [14]

Sass/Pienkos/Škodlar/Stanghellini/Fuchs/

Parnas/Jones

132.239.1.231 - 3/10/2017 3:39:00 AM

Univ. of California San Diego

Downloaded by:

3.12.2 People Seem Unfamiliar in a Strange Way

People who are in fact well known to the subject, and whose appearance is recognized, nevertheless have a strik- ingly unfamiliar quality. This may or may not involve a con- viction that the other individual must actually be an un- known person, perhaps disguised as an intimate (in which case 3.12.3, People seem disguised*, should also be scored). NB: If nonhuman objects, situations, or events are also in- cluded in this feeling, score also 5.6, Jamais vu experiences.

• “I knew her name and everything about her, yet she appeared strange, unreal, like a statue… I was in the presence of a strang- er.” [18] (also score 3.9, Depersonalization of others)

3.12.3 People Seem Disguised*

People seem somehow to be hiding or covering up their true identity. The subjects may experience this item in conjunction with (especially as an explanation for) deper- sonalization and changes in familiarity. The subject may speak of people “going incognito” or somehow “pretend- ing” to be someone other than who they are.

3.12.4 People Seem Threatening in a Strange Way*

There is something about the appearance of other peo- ple, a strange or uncanny quality, that seems to indicate that others are threatening in some way. NB: This may also be combined with 3.4.2, Feelings of social paranoia or so- cial anxiety*, and 3.4.3, Pervasive mistrust of others*.

• “He noticed odd behavior in an acquaintance which made him feel strange… A passer-by gave such a penetrating glance, he could be a detective.” [14]

3.12.5 General/Unspecified Changes in the Physical

Appearance of Others (=BS C.2.3.5) The subject perceives the physical features, such as the face and body, of other people as changed, distorted, de- formed, or unnatural in some strange way. For example, the color or look of the face, eyes, or hair can appear al- tered, though not necessarily in a literal fashion.

• “People appeared too fat or meager, somehow disfigured and not like they normally look.” [1]

• “[People’s] faces rearrange sometimes, if I stare at them for too long and I lose track of what they’re saying. They become very kaleidoscopic. And faces start to rearrange.” [unpublished data]

• “My husband’s eyes changed from bright blue to dark brown.” [1]

3.13 People Seem as if Communicating Something Special or Unusual (beyond the Obvious) (BS C.1.17)

Feeling as though other people are hinting at or convey- ing some special message, which is often directed toward or intended especially for the subject. What other people

EAWE: Examination of Anomalous World Experience

mean may be quite remote from what they actually say. The subject may or may not be able to identify the con- tent or meaning of the message.

3.13.1 Paranoid Significance*

The special communication is experienced as indicat- ing dislike, criticism, accusations, malevolence toward, or a plot against the subject.

• “Everyone was playing language games … as a way of persecut- ing me … with people using gestures, nods, and smiles to con- firm to each other that I was the intended reference.” [49]

• “She asked if I wanted them by Saturday. She meant I was a tart.” [47]

3.13.2 Grandiose Significance *

The special communication is experienced as indicat- ing the subject’s unusual powers or superiority over others.

• “I would hear people say that to me [that I was early or I was late], people in crowds, and I would have a lot of delusions around that: I thought that I was supposed to stop time, and that was my goal.” [unpublished data]

3.13.3 Metaphysical Significance

The special communication is experienced as indicat- ing an overall change in the very fabric of the universe, such as the coming end of the world or some other metaphys- ical meaning.

• Other people somehow conveyed “… that the world was com- ing to an end and that the result of this was that the world was constantly referring in a coded way to its own collapse.” [42] (also score 5.16, Experiences of the end of the world)

3.13.4 Unknown/Unstatable Significance

Communication from person or people has a special meaning for the subject, but he is unable to say what it is.

• “I couldn’t understand what anybody was actually saying to me, so when they would talk to me, on some level I … got over- whelmed by all of these other sorts of secret messages they were trying to send me.” [unpublished data]

3.14 Anomalous Behavioral/Attitudinal Responses to Others

The subject is aware of acting – often of feeling com- pelled to act – in unusual or remarkable ways when engag- ing with other people, e.g., to withdraw, rebel, conform, observe, etc., often in association with profound anxiety, interpersonal threat, or perplexity. Subtypes may have a more involuntary/automatic (perhaps catatonic) or a more willful/active (“antagonomic” [41]) quality; the interviewer may find it useful to inquire into this.

Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

31

Univ. of California San Diego 132.239.1.231 - 3/10/2017 3:39:00 AM

Downloaded by:

3.14.1 Active Withdrawal*

The subject feels obliged or inclined to withdraw from others, for example, by shutting herself in her room or home, because of feelings of anxiety, fear, or discomfort in interpersonal interactions.

• “I try to keep things at a distance, because the fate of others gets so much under my skin, I cannot cope with it. I avoid every conversation, because it excites me too much. If somebody comes for a visit, I retire.” [1]

3.14.2 Oppositional/Rebellious Behavior *

The subject feels obliged to oppose or resist others. This can include refusing to comply with an interlocutor’s re- quests (opposition), turning away from the interlocutor when he speaks (aversion), and doing the opposite of what is requested (negativism).

• “I reject my tendency towards identifying myself with what the others say.” [41]

3.14.3 Social Disinhibition *

The subject is aware of acting in a way that suggests indifference to social norms – whether because of actively disregarding or being oblivious to social expectations.

• “People buy a ticket to get on a train – that is the rule. But this rule is for them, not for me.” [41]

3.14.4 Compulsive Interpersonal Harmony*

The subject feels his relationships must be constantly and completely harmonious and benign, utterly devoid of conflict. For example, the subject may describe feeling “unable to disagree” or as though he must always “go along” with others.

3.14.5 Extreme Compliance

The subject is aware of behaving in a highly imitative or compliant manner, suggestive of something more than mere social conformity. The subject may describe this as involving “automatic” obedience, or almost “me- chanical” compliance with the interlocutor’s request, or as a kind of mirroring echopraxia (mimicking the movement of another); the interviewer should note de- tails.

3.14.6 Compulsive Clownery/Entertainment of

Others* The subject feels as though she must “play the fool” or engage in clownish behavior or “buffoonery” [50] when around others, perhaps in response to anxiety, perhaps

32 Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

expressing disdain/superiority. This has a stilted, auto- matic, or extreme quality that goes beyond more mun- dane propensities to be entertaining.

4 Language

General Description. The 10 items in Domain 4 refer to anomalous ways of experiencing language, whether one’s own or that of other people. The focus here is on the sub- jective experience of words and meaning, flow of speech, grammar, verbal concepts, and problems of verbal expres- sion (not on verbal behavior or implicit linguistic struc- tures). Changes in this domain may be particularly diffi- cult for subjects to notice in themselves. Interviewers may need to pose their queries in several ways, phrasing initial questions in general terms before asking about specifics; e.g., before querying 4.4, Unconventional word choice, grammar, tone, or cryptic discourse, one might ask: “Are you aware of wanting to use language in an unusual way?” or “Are you bothered by language, or drawn to speaking or using language differently from most people?” During the interview, interviewers may notice certain anomalies of speech that, however, are not acknowledged by the subject when the relevant EAWE item is queried. In this case, one should consider gently asking the subject about her perception of these anomalies, but only at the end of the EAWE interview (so as not to disrupt rapport). If the subject continues to deny such anomalies, despite manifest- ing them, interviewers should note the behavior but with- out giving an EAWE rating (since the EAWE concerns the subject’s experience). It is possible that an interview subject might describe having had some anomalous experiences of language, yet not respond affirmatively to what seems the relevant EAWE question nor otherwise describe the experi- ence in a clear, conceptual manner. In such a case, the in- terviewer should score the item, since the interviewee’s de- scription does indicate some awareness on his/her part.

4.1 Basic Disruptions of Standard Verbal Comprehension (BS C.1.6)

The subject experiences difficulty understanding speech or written language, including the meanings of words, sentences, or sequences of sentences. This may oc- cur when reading/listening to others but also when speaking/writing.

4.1.1 Meaning/Sound Dissociation The subject experiences difficulty putting sounds (or appearances) of words together with their meanings (pho- netic with semantic).

Sass/Pienkos/Škodlar/Stanghellini/Fuchs/

Parnas/Jones

132.239.1.231 - 3/10/2017 3:39:00 AM

Univ. of California San Diego

Downloaded by:

• “But what is a train? It’s a word. The word has nothing to do with a solid thing like a train.” [22]

• “I said ‘chair, jug, table, it is a chair.’ But the word echoed hol- lowly, deprived of all meaning; it had left the object, was di- vorced from it … a name, robbed of sense, an envelope emp- tied of content. Nor was I able to bring the two together…”

[18]

4.1.2 Distraction via Semantic Possibilities

The subject thinks about many possible meanings of a given word or phrase, or has difficulty determining the sense in which a word is being used, which can result in losing track of what he is hearing/reading/saying.

• “… everything that I read had a large number of associations with it…everything that sort of caught my attention seemed to start off, bang-bang-bang, like that with an enormous number of associations moving off onto things so that it became so dif- ficult for me to deal with that I couldn’t read.” [22]

4.1.3 Distraction by Individual Words

The subject experiences a tendency to get stuck and/or focus on individual words or phrases and, therefore, loses track of the overall meaning and intention at sentence or paragraph levels.

• “Reading, I often wonder about common words and have to think about their meaning.” [1]

4.1.4 Unspecified Difficulty Understanding

The subject experiences difficulty when reading or lis-

tening.

• “More and more, I just read over lines without comprehending what they mean.” [1]

• “When people are talking I have to think what the words mean.”

[12]

• “Sometimes when people speak to me my head is overloaded. It’s too much to hold at once…It’s just words in the air unless you can figure it out from their faces.” [12]

4.2 Difficulty Understanding Emotional/Expressive Aspects of Speech*

The subject experiences difficulty recognizing emo- tional intonations in others’ speech, which may result in failing to understand emotional nuances in communi- cation.

• “I hear people talking but I did not grasp the meaning of the words. The voices were metallic, without warmth or color.”

[18]

EAWE: Examination of Anomalous World Experience

4.3 Specific Changes in Standard Feel or Meaning of Words ( BS C.1.6)

The subject experiences, and may use, words in ab- normal ways, whether by focusing on physical qualities of words, assigning new meanings, viewing words as absurd or arbitrary, or even seeing words as having a kind of life of their own. NB: Unlike 4.1, Basic disrup- tions of standard verbal comprehension, and 4.2, Dif- ficulty understanding emotional/expressive aspects of speech*, instances of 4.3 need not necessarily be expe- rienced as disrupting comprehension, though that is possible.

4.3.1 Focus on Sound or Appearance of Words or

Phrases* The subject experiences a tendency to be unusually aware of the shape and/or physical appearance of written language, or sound quality of words. NB: If this disrupts meaning, also code 4.1.1, Meaning/sound dissociation.

• “Words have their own textures, which may not be the same as the texture of the things they represent.” [22]

4.3.2 Unconventional Semantic Determination

Via signifier or fragments of words. The subject is aware of experiencing meaning as de- termined by the specific sound or look of words, or by

parts of words (phonemes or syllables), rather than by conventional referential meaning, or may simply focus on parts of the word rather than the usual signifying unit.

• “ MAMMA for me meant that from the beginning we are the two of us (M), then we are alone (A), then we are together for a long time (MM), but at the end we are alone again (A). Letter after letter I wanted to see if the string of letters corresponded the original meaning.” [51]

• “Contentment? Well uh, contentment, well the word content- ment, having a book perhaps…but when you come to the word “men” you wonder if you should be content with men in your life and then you get to the letter T and you wonder if you should be content having tea by yourself or be content with having it with a group and so forth.” [22]

4.3.3 Words Seem Arbitrary/Absurd

The subject is abnormally aware of the arbitrariness of words, sometimes to the point of being unable or unwill- ing to accept standard usage or attend fully to the intend- ed meaning of the communication.

• “I don’t understand why this has to be called a table, and if the sun’s out we have to say it’s a nice day.” [41]

Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

33

Univ. of California San Diego 132.239.1.231 - 3/10/2017 3:39:00 AM

Downloaded by:

4.3.4 Words or Language Seems Alive,

Quasi-Physical, Strangely Powerful Words or sentences are experienced as somehow having a “life of their own” or become strangely “thing like.” The subject may feel that language is somehow determining itself or that language or words seem like “sacred objects, imbued with a magical power.” [52]

• “Words breathe, they blink; they are capable of transforming the world and themselves.” [53]

• “One word stood out of the sentence…That word became as something material, nearly a thing for me, or an image in front of me.” [51]

4.3.5 Egocentric Linguistic Reference (BS C.1.17)

Specific words or other linguistic items are experienced as having special reference to the subject. The issue here is not the content of a particular utterance or written mes- sage, but a more fundamental sense that a word or words (or something inherent to the linguistic medium itself) is somehow about the subject.

• “Any word that could be taken as referring to me, even by

oblique references, was interpreted that way…” America’ could be taken to mean “Am Erica,” i.e., a coded reference to someone who thinks he’s a woman. I would then take that to mean that

the group accepted that this referred to me ”

[49]

4.4 Unconventional Word Choice, Grammar, Tone, or Cryptic Discourse (BS C.1.7, EASE 1.17)

The subject uses, withholds, or strings together words in anomalous ways that impede understanding by others. This can sometimes be willful or quasi-willful; the inter- viewer should note details.

4.4.1 Cryptic, Telegraphic, or Ungrammatical

Speech The subject is aware of adopting, allowing himself to use, or finding himself using speech that is telegraphic (omitting many words, perhaps seeming cryptic to oth- ers) or somehow lacking usual grammatical structure. The subject may describe intentionally speaking “non- sense” or going “into his ‘schizy’ mode of speaking” more or less at will just to obscure his meaning or somehow test other people [22].

4.4.2 Stock Words

The subject reports fixing on a conventional word to convey many meanings beyond those it would normally signify. Can involve repetitive overreliance on one or a few words, with the subject’s speech or writing taking on a stilted or impoverished quality.

34 Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

• “Thus one patient used the word “vessel” for nearly all objects and called a watch a “time vessel.” [24]

4.4.3 Made-Up Words ( Neologisms ) or

Unconventional Usage The subject is aware of using words she has made up, or of using existing words in a way that is, semantically, grossly idiosyncratic. There may be a sense of conceptual play, a desire to create a private language, or an inability to come up with the standard word; the interviewer should note details.

• “If I could not immediately find an appropriate word to express the rapid flow of ideas, I would seek release in self-invented ones, as for example wuttas for doves.” [50]

• “I built words that did not exist because my experiences needed something that went beyond [ordinary language].” [51]

4.4.4 Mannerisms and Stilted Speech

The subject reports experiencing language as a highly mannered or stilted medium – perhaps overly “artificial” or “formal” – and may report exaggerating these qualities in his/her own speech or pronunciation [24] .

• One patient “expressed trivialities in the most lofty, affected phrases, as if he were dealing with the highest interests of man- kind.” [54]

4.5 Disturbed Fluency (BS C.1.7, EASE 1.17)

The subject is aware of finding it hard to express her- self, due to an impairment in or retardation of word flu- ency, precision, or availability, or to some other felt inad- equacy of her verbal expression (as opposed to the issue of ineffability, as with item 4.9.1, Language inadequate to express unusual experiences*). The subject senses a diminished ability to use language as a tool to convey meaning and may experience associated hyperaware- ness of the linguistic medium.

4.5.1 Unavailability of Words

The subject describes feeling as though she is unable to “find the right words” to describe her experience. NB: In contrast to 4.9, Ineffability: inadequacy of language to describe or express, here the person feels that she cannot

manage to find or summon the right words, rather than that adequate or appropriate words do not exist.

4.5.2 Unfocused or Disorganized Thoughts Preclude

Verbal Expression The subject is unable to adequately express himself (or to speak at all) because of difficulty focusing on a particular theme or line of thought – as if his thoughts were too nu-

Sass/Pienkos/Škodlar/Stanghellini/Fuchs/

Parnas/Jones

132.239.1.231 - 3/10/2017 3:39:00 AM

Univ. of California San Diego

Downloaded by:

merous or too disorganized to allow for, or to be trans- lated into, linear verbal expression.

• “Thoughts were so numerous that I didn’t manage to talk.” [55]

4.5.3 General Discordance between Intended

Expression and the Expressed (=BS A.7.2, =EASE

1.16)

“Subjective experience of not being able to express one- self according to one’s actual feelings and emotions [or thoughts]. The [subject] experiences that his speech…[is] not in line, or congruent, with what he feels [or thinks]; his expressivity is felt to be disfigured and distorted and somehow beyond self-control.” [2]

• “It’s like I can’t help but express things in a way that would leave a different impression and not even realize it.” [unpublished data]

• “It leads to me trying to express something serious, but my ex- pression is so messed up that certain details are distorted; with the changes in details, it no longer seems so serious.” [unpub- lished data]

• “I thought my language was wrong. I believed that no one could understand what I said. I couldn’t understand what I said. Just high-pitched noises came.” [33]

4.6 Disturbed Relevance (BS C.1.7)

The subject is aware of problems with staying or being on track when speaking or writing.

4.6.1 Derailment*

The subject is aware of a tendency to forget or lose track of the initial or overall goal of her statement when speaking

or writing, so that the act of verbal expression lacks gen- eral coherence (showing a “loosening of association” more extreme than the normal shifts of conversational flow). The subject may be aware of being distracted by intruding associations that get her “off track” or “change the subject,” of having trouble deciding what is relevant, or perhaps of simply lacking much sense of where her thinking/talk was going. (Interviewer should note any comments relevant to this distinction.)

• “My thoughts get all jumbled up. I start thinking or talking about something but I never get there. … People listening to me get more lost than I do…” [12]

• “I often don’t know which details to include and I can also bring up a bunch of irrelevant stuff because I don’t know if it’s rele- vant.” [unpublished data]

4.6.2 Tangential Responding

The subject reports awareness of responding to ques- tions or statements by others in a way likely to seem oblique, “irrelevant,” or “off the point.Missing here is clear rele-

EAWE: Examination of Anomalous World Experience

vance to the other person’s comment or question (rather than the continuing coherence of one’s own speaking once underway).

4.7 Disturbance of Linguistic Engagement or

Purposefulness

The subject is aware of adopting or manifesting an odd manner or style of expression, which somehow lacks the usual sense of emotional or volitional engagement.

4.7.1 Aprosody ( Lack of Emotional Intonation ) *

( BS A.7.2 )

The subject experiences her own speech as lacking nor- mal emotional intonation, perhaps describing it as “flat,” “lifeless,” or “dead”; and may report a loss of ability or de- sire to convey her feelings or emotions through language.

4.7.2 Echolalia ( BS C.3.1 )

The subject reports feeling a need or automatic ten- dency to repeat, “echo,” or otherwise accompany the speech of her interlocutor.

4.7.3 Speech Feels Autonomous ( BS C.3.1 )

Sense of one’s own speaking (or writing) as happening independently of oneself, perhaps under external control. Can result in pressured speech or even loss of coherence

as meanings become increasingly muddled.

• “One patient…would say of his speaking that ‘someone is con- trolling me,’ that ‘it goes out all by itself,’ or that ‘I am being forced to talk.’” [22]

4.8 Anomalous Experience of the Abstract and the

Concrete

Difficulty accepting or understanding abstract or gen- eral concepts, abnormal interrelation between the ab- stract and the concrete, or heightened focus on what is highly abstract/general or else concrete/specific.

4.8.1 Difficulty with or Dislike of Abstract or General

Concepts ( BS C.1.16) The subject finds general or abstract concepts or symbols (e.g. as expressed in aphorisms or a proverb) to be arbi- trary, absurd, or simply difficult to understand. Can involve a tendency to describe and understand things in very lit- eral terms, to emphasize individual instances, or to focus on immediate sensory experiences or on unique and inef- fable inner feelings or sensations.

• “I have difficulties now to understand the symbolic meaning of sayings or fables that I had not before.” [1]

Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

35

Univ. of California San Diego 132.239.1.231 - 3/10/2017 3:39:00 AM

Downloaded by:

• “I cannot recognize anymore that a certain object or event only stands as a symbol or metaphor for something more general, abstract or philosophical.” [1]

4.8.2 Abstract Rendered in Unusually Concrete

Terminology ( BS C.1.16 ) The subject is aware of using unusually concrete lan- guage to describe abstract concepts, e.g., describes time as a “door” or anger as “arrows.” (Interviewer should re- cord the example.) NB: If this concrete rendering occurs in a perceptual rather than linguistic fashion, see item 5.9.1, Physical or literalist instantiation of abstract meaning.

4.8.3 Specific or Concrete Meanings Rendered in

Unusually Abstract or General Terminology (Interviewer should record the example.) NB: If this co-occurs with unusual categorization, see also 5.9.2, Anomalous classification.

• “Refers to a candle as a ‘night illumination object,’ a dustpan as a ‘domestic utensil.’” [22]

4.8.4 Hyperabstract or Vague Discourse

Awareness of a tendency to speak in a manner that can sound (perhaps especially to others) excessively abstract or general, or vague to the point of being difficult to follow or remember (akin to so-called “poverty of content” of speech).

• “One talks and it seems one says nothing and then one finds one has been talking about the whole of one’s existence and one can’t remember what one said.” [56]

4.9 Ineffability: Inadequacy of Language to Describe or Express (May Include Temptation to Remain Silent)

The subject experiences language as inadequate or profoundly inauthentic, incapable of describing or ex- pressing what really matters. This may involve inclina- tions to remain silent, at least on certain matters.

4.9.1 Language Inadequate to Express Unusual

Experiences* The subject feels that language is incapable of capturing his experiences because of the highly unusual nature of his own experiences. This may be related to the subject’s ten- dency to focus on the ineffable (e.g., experiences too uni- versal, pervasive, or abstract, or else too minute, specific, or concrete, to be captured in words). NB: The unusual or strange nature of a subject’s own experience must be clearly mentioned.

36 Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

• “There are things I’ve experienced that are totally outside the scope of my prior experiences but that I cannot describe (or even begin to describe); there is no way of expressing them.” [unpublished data]

• “Again it is extremely difficult to describe these changes in words because matters are dealt with which lack all analogies in human experience…” [57]

4.9.2 General Feeling of the Inadequacy of Language The subject feels as though linguistic expression were – by its very nature – somehow pointless, impossible, or deep- ly inadequate or inauthentic. There may be a sense of opt- ing out of the symbolic or linguistic world, or that language by its very nature is unable to serve as a means of true com- munication or mutual understanding, specifically because of the abstract, generalizing, or conventional nature of its concepts. The subject may feel that she must, or wishes, to avoid speaking (or writing), or that she must go into ex- treme detail in order to adequately express her experience. NB: Unlike 4.9.1, Language inadequate to express unusual experiences*, here the subject makes no specific mention of the unusual nature of her own experiences.

• “I am blocked by the limitations of inadequate words…” said a patient, explaining her silence as due to her “inadequacy to use language to express what lies buried so deeply inside me.” [22]

• “I find that I cannot…accept the inadequacy of abstract or gen- eral language to fully capture and communicate whatever I want (or feel I need) to think or express.” [unpublished data]

• “I go into such detail because I tend to find normal, simple lan- guage to be inadequate for describing the complexity of my experience.” [unpublished data]

• “Everything is too nuanced. There are subtleties that one can- not express.” [37]

4.10 Alienation from Self-Description

The subject experiences a profound sense of distance or disconnect when describing himself or his experiences, as if he were “speaking about someone else.” This is not due merely to a felt contrast between the present emo- tional state and remembered experiences, but seems to involve a difficulty feeling able to identify with the self who is being described (even though it is himself).

5 Atmosphere (Anomalous Feelings of Altered Reality, Familiarity, Meaningfulness, Causal Relationships, Intensity, or Emotional Tone)

General Description. The 17 items in Domain 5 refer to anomalies in experience of the overall quality, feel, or or- ganization of the external world. Here, we are concerned with subtle, pervasive, or uncanny qualities that pertain to

Sass/Pienkos/Škodlar/Stanghellini/Fuchs/

Parnas/Jones

132.239.1.231 - 3/10/2017 3:39:00 AM

Univ. of California San Diego

Downloaded by:

the general “horizon,” ambiance, structure, mood, or at- mosphere of the entire lived world – how things in general seem to the subject. These features are everywhere and no- where; they are difficult to isolate or describe because of their encompassing nature. It is not necessary for abso- lutely all aspects of a subject’s experience to be affected by these changes; the emphasis, however, is on something pervasive or mood-like in the change, which may be fixed on certain things or may infuse an entire lived world.

5.1 Derealization of the World (BS C.2.11.1, EASE 2.5.1)

“A change in the experience of the environment: the surrounding world appears somehow transformed, un- real, and strange, and may be compared to an ongoing movie.” [2] “Derealization” is a broad and ambiguous term; here, we employ it only regarding experiences in- volving diminished sense of immediacy, actuality, useful- ness, relevance, authenticity, vitality, or dynamism. (Ex- periences of hyperrealism or of solipsism are classified in other items below.) This is distinct from a hallucina- tory or delusion-like distortion of reality: not a failure to recognize the identity of people or things but an experi- ence of subtle but pervasive change in the feeling/sense or felt reality of the world. The change occurs without loss of reality testing. It should be noted if it occurs after or associated with a panic attack.

5.1.1 Remoteness or Barrier ( Plate-Glass Feeling ) *

( EASE 2.4.2 ) Feeling as though cut off from the world, as if the world existed at a remote distance or beyond a transparent bar- rier.

• “Everything appears as through a veil; as if I heard everything through a wall.” [14]

• “Things do not feel real. There is something between me and the things and persons around me; something like a wall of glass between me and everything else.” [58]

5.1.2 Decreased Intensity or Substantiality*

The subject experiences a general decrease in the inten- sity or substantial quality of the world, without emphasiz- ing any particular sensory mode. The subject may de- scribe the reality or being of everything as somehow “sub- dued,” “diminished,” “flat,” or “hollow.” (Can obviously overlap with other subtypes.)

• Subject describes world feeling “thin as plastic,” “immaterial,” or like “floating images,” “shells with nothing inside” or “a paste- board house,” [21] or perhaps as “strange, two-dimensional” or “only silhouettes.” [2]

EAWE: Examination of Anomalous World Experience

5.1.3 Deanimation *

Overall sense that things – e.g., a tree or a landscape – seem less animate or more lifeless and mechanical than they usually would. NB: If persons only, see item 3.9, De- personalization of others, above.

• One patient described a schoolyard as “limitless, unreal, me- chanical and without meaning.” [18]

• “…Things…more artificial, detached one from the other, un- real, without life.” [18] (also score 5.1.4, Falseness)

5.1.4 Falseness ( = EASE 5.5 )

Everything seems somehow fake, fraudulent or phony, illusory, or “shammed” [50], perhaps theatrical or like car- toons or mere simulacra. World may be experienced as artificial or as merely “virtual,” reminiscent of such films as “The Truman Show” or “The Matrix.”

• A Russian patient in the Burghölzli asylum in Switzerland claimed that “an identical duplicate ‘Russian Burghölzli’ had been erected.” [50]

• “As a child she experienced that ‘the whole world was built up just for her,’ like a scene.” [2]

• “You can’t imagine what it is like to know everything is simu- lated. Having dinner – even at my grandma’s house! – seems faked!” [59]

5.1.5 Loss of Enticement Quality*

The subject feels as though objects have no use or ap- peal to action for him (though he may still recognize their common sense or practical significance). For example, he may have no trouble recognizing something as a hammer (i.e., it does not present itself as a mere geometrical form) but is unable to register or conceive of its practical use or relevance for himself. NB: This may overlap with or ac- company 5.2, Loss of affordances, though it may also oc- cur with affordances intact.

• “… more and more, despite my efforts, I lost the feeling of practical things.” [18]

5.1.6 Static Quality, Stillness, or Morbid

Intellectualism World is experienced as dominated by fixed, static, geo- metric, or purely rational qualities or aspects, while ac- tions, dynamic processes, and flexible or malleable as- pects lose importance (includes Minkowski’s [38] “mor- bid geometrism”).

• “I like immovable objects, boxes and bolts, things that are al- ways there, which never change.” [60]

• People are perceived as “truncated,” like “perpendicular lines,” “stripped of their flesh” or having a “trapezoid head.” [21]

Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

37

Univ. of California San Diego 132.239.1.231 - 3/10/2017 3:39:00 AM

Downloaded by:

• “[One patient] lived for ideas and saw people as impersonal objects.” [60] (also score 3.9.3, People seem mechanical)

5.1.7 Nonspecific/Other Derealization * The subject describes things as strange or derealized but cannot specify how this is so, or his/her descriptions do not fit any previous subtypes.

• “Patient experiences other people as robots and everything as a big pot of molecules, and then starts wondering if the world is real.” [2] (also score 3.9.3, People seem mechanical)

• “All objects appear so new and startling I say their names over to myself and touch them several times to convince myself they are real. I stamp on the floor and still have a feeling of unreal- ity.” [14] (also score 5.6, Jamais vu experiences).

5.2 Loss of Affordances

Practical and conventional meanings of objects and events disappear, replaced by a purely geometrical, visual, or perhaps aesthetic mode of perception. NB: This may or may not overlap with 5.1, Derealization of the world, especially 5.1.5, Loss of enticement quality*.

• “Objects are stage trappings, placed here and there, geometric cubes without meaning.” [18] (also score 5.1.4, Falseness; con- sider 5.1.5, Loss of enticement quality*)

• “When, for example, I looked at a chair or a jug, I thought not of their use or functions – a jug not as something to hold water and milk, a chair not as something to sit in – but as having lost their names, their functions and meanings….” [18] (consider also 5.1.5, Loss of enticement quality*)

• “A gardener sweeping a path fifty yards away is ‘a long streak with something moving backwards and forwards towards the top of it’.” [15]

5.3 Inanimate Things Seem Alive or Intentional*

Objects and things that are nonliving/inanimate seem somehow alive, or like they give off or are infused with a special energy that makes them seem autonomous and living. Objects may even seem to be expressing or com- municating some meaning (typically to the subject) in an animate or human-like fashion.

• “Obstacles, chairs, buildings took on a life of their own. They seemed to make threatening gestures, to have an animistic out- look.” [13]

5.4 Heightened Intensity/Hyperrealization * ( BS

C.2.11.2, EASE 2.5.2)

The subject experiences a general increase in the in- tensity of the world, not specific to any particular sense or mode of perception. Objects and things just seem more striking than usual, somehow more intense and demand- ing of the subject’s attention.

38 Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

• “Just as the perceptual world may be experienced as something strange or dead, so it can be experienced as something entirely fresh and of overpowering beauty.” [14]

• “The behavior of the dog made a strong impression on me; it was so wild, uncontrolled, so full of pure nature, savage and instinct-driven … the whole landscape was so authentic, so primordially natural it was all so moving that I felt an immense happiness.” [2]

5.5 Déjà Vu Experiences (=BS C.2.11.3)

The subject describes experiencing an abnormal sense of familiarity, such that things, situations, or events not previously experienced nevertheless seemed familiar. Often felt to be somehow more intense or significant than the everyday déjà vu experience. NB: If experience involves people, score also 3.12.1, People seem familiar in a strange way.

• “The very same visitor in exactly the same clothes was here one year ago today and said the same things.” [50] (consider also 3.12.1, People seem familiar in a strange way)

• “When I heard the news I felt I had heard it before.” [28]

• “I felt I had already done those things.” [28]

5.6 Jamais Vu Experiences

The subject perceives a previously encountered ob- ject, scene, situation, or concept (which he knows he has encountered before) as though he had no prior experi- ence of it, as if he were seeing it for the first time – as unfamiliar, perhaps incomprehensible [14]. NB: If ex- perience involves people, score also 3.12.2, People seem unfamiliar in a strange way. Compare with 2.4.2, Constant surprise due to the inability to anticipate fu- ture events.

• “I knew it was my room, but I felt as if I’d never set eyes on it before.” [15]

• “It’s just as if I’ve visited a place for the first time…” [33]

• “I suffer from a diminution of memory, or something like that:

many concepts suddenly seem so strange to me. I have to get used to them again each time. They seem new to me, even though I have not exactly forgotten them. They are just so un- usual then.” [37]

5.7 Perplexity

A profound and disturbing sense of being perplexed or confused by the overall sense of reality.

5.7.1 Confusion of Realms (=BS C.1.15, EASE

1.10)

The subject experiences a merger or confusion be- tween different realms or universes associated with dif- ferent experiential modalities; that is: difficulty distin-

Sass/Pienkos/Škodlar/Stanghellini/Fuchs/

Parnas/Jones

132.239.1.231 - 3/10/2017 3:39:00 AM

Univ. of California San Diego

Downloaded by:

guishing between, e.g., perception and imagination, mem- ory and imagination, or memory and perception.

• “I don’t know, when I talk to you [his therapist] whether I’m having a hallucination, or a fantasy about a memory, or a mem- ory about a fantasy.” [22]

• “I have a really difficult time distinguishing between dreams and reality… I’ll have dreamed about something, and then it happens, and it’s this really weird doubling of the experience because I feel like I’ve already had the experience. Sometimes when you first wake up from a dream [normally] you’re a little uncertain, but this just endures.” [unpublished data]

• “Real day time scene seems to be part of a dream that I had.”

[28]

5.7.2 Unreal Interferes

The subject’s ability to appreciate or function in every- day reality is disrupted by her preoccupation with or dis- traction by an imaginary, delusional, or solipsistic world (with or without clear understanding of the distinction between real and imaginary).

• “When people were talking to me… instead of hearing what they were actually saying, I would hear something else that in- volved my delusions.” [unpublished data]

5.7.3 World Experienced as Incoherent, Disoriented

The person may feel that the world in general is los- ing its internal order and coherence and has become meaningless and puzzling. This may be associated with feeling of having no stable point of orientation or point of view.

• “I…sought some fixed point, but found none…The muchness and the motion were too much and too fast. Everyone withdrew from everyone. There was a running as of something liquefied, a constant going forth, as of evaporation. Everything was sche- matic, ghostlike, even myself.” [22] (consider also 1.8.3, Loss of spatial integrity or structure, and 5.1.2, Decreased intensity or substantiality*)

• “Reality is too complex. I cannot find key rules.” [39]

5.7.4 Perplexing Hyperawareness of Tacit

Dimension Aspects of action or interaction that would normally be tacit emerge from the background of awareness. The subject describes difficulty engaging with the world in a natural, prereflective way, largely because of a hyperreflex- ive tendency to become aware of implicit rules, common- sense assumptions, or automatic aspects of action (e.g., be- coming fixated or “hung up” on why an action is done in one way rather than another [37]). NB: This may be found alongside 3.1, Lack of social understanding or interper- sonal attunement (hypoattunement).

EAWE: Examination of Anomalous World Experience

• “[The patient] felt paralyzed…his hands could no longer grasp, for who was it that gave them the right to take things? His feet could no longer walk, for who could ensure ground for their steps?” [61]

• “The more I focus on my breath, I feel like I’m either not breath- ing or I’m hyperventilating…I feel like I’m constantly working on just being…I have to think about doing everything.” [un- published data]

5.8 Anomalous Manner of Ascribing or Perceiving Meaning

There is a strange quality to the manner or process by which objects of awareness come to be experienced as hav- ing meaning, or inspire ascription of meanings.

5.8.1 Meaning Imposed on Object by Subject

The subject feels obliged to give a special or new mean- ing to an object, often in a compulsive manner. The mean- ing may or may not have something to do with the ob- ject’s appearance or perceptual salience; it may also be associated with feelings of uncanny particularity.

• “The patient observed that he was ‘compelled to give things a second meaning.’” [19]

5.8.2 Meaning Inherent in the Object Itself

The new and special meaning somehow appears simul- taneously with the perception of the object, experienced di- rectly as an integral part of the object, without the subject feeling that this meaning is deduced or derives from him. Akin to “delusional percept” [62], though without neces- sarily having a fully delusional quality.

• “Suddenly things seem to mean something quite different. The patient sees people in uniform in the street; they are Spanish soldiers. There are other uniforms; they are Turkish soldiers. Soldiers of all kinds are being concentrated here.” [14]

• One patient “sees incorporated in the white bark [of a birch tree] a very definite quality, namely that of innocence” (as op- posed to seeing it as a symbol of innocence). [19]

5.8.3 Proliferation of Meanings from the Object

Perceived or thought. Something perceived, remem- bered, or thought gives rise to a plethora of associated thoughts. NB: If related to language, score item 4.1.2, Distraction via semantic possibilities.

• “My trouble is that I’ve got too many thoughts. You might think about something, let’s say that ashtray and just think, oh! Yes, that’s for putting my cigarette in, but I would think of it and then I would think of a dozen different things connected with it at the same time.” [12]

Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

39

Univ. of California San Diego 132.239.1.231 - 3/10/2017 3:39:00 AM

Downloaded by:

5.9 Anomalous Forms of Meaning

These anomalous forms of meaning involve unusu- al literalness/concreteness or abstractness/generality. The perceived meaning is anomalous in its form or structure, in ways that imply unusual literalness or con- creteness, or else exaggerated abstractness or generality.

5.9.1 Physical or Literalist Instantiation of Abstract

Meaning The subject finds that highly abstract thoughts or con- cepts (e.g., love, politics, truth, or reality in general) or feelings take on a somehow literal, objectified, even con- crete quality that can manifest as recognizable (material) objects or in their experience of the world. NB: If regard- ing language, see item 4.8, Anomalous experiences of the abstract and the concrete.

• “I have sometimes seen my thoughts floating around outside my window like leaves or snowflakes.” [unpublished research]

5.9.2 Anomalous Classification

The subject experiences a tendency to perceive signifi- cant similarities between objects or things that are not ob- vious to other people, or is inclined to classify things in an unusual, sometimes hyperabstract, manner. NB: This is not just a matter of offering an abstract definition (as in 4.8.3, Specific or concrete meanings rendered in abstract or general terminology) but of suggesting a highly uncon- ventional classification or categorization.

• “Parents are the people that raise you. Anything that raises you can be a parent. Parents can be anything, material, vegetable, or mineral, that has taught you something…Rocks, a person can look at a rock and learn something from it, so that would be a parent.” [22]

• One patient classified “table” and “chair” not as furniture, but as “objects in the universe.” [22]

5.10 Intensified Awareness of Patterns or Trends*

The subject is acutely aware of patterns or trends, which typically have the potential to seem meaningful, nonaccidental. NB: This may also involve 1.4.3, Captiva- tion of attention by isolated details, and 5.14, Revelatory or pseudorevelatory (apophanous) mood.

• “I always know how many red cars I have seen today. It seems my attention is overtuned.” [unpublished data]

5.11 Anomalous Sense of Causal Relationships

A change in the normal sense of cause and effect or of the patterning of events, such that things seem oddly con- trolled, predetermined, or planned. NB: Overlappings

40 Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

with Domain 2: Time and events, can be prominent here. NB: For experiences that seem antithetical to this item – that is, when ongoing events or actions seem ar- bitrary or random, without cause or reason – consider items 2.3.2, Time as disjointed or fragmented, 2.4.3, Feeling that “anything could happen,” and 6.2.2 Con- ceptual freedom/anything goes.

5.11.1 Actions or Events Seem Controlled by an

External Force or Will The subject experiences events as somehow under the direct control of some external being, force, or hidden sub- jectivity.

• “…the coming into existence of such life [patient is explaining the appearance of insects before his gaze] is due to the purpose- ful manifestations of divine power of will or divine power of creation.” [57]

5.11.2 Actions or Events Seem Predetermined or

Planned Everything seems somehow just so, nonaccidental or in- tentional, with no allowance for the possibility of ran- domness – sometimes associated with apathy regarding the worth of taking any action (without clear statement regarding external or divine force, as in the previous item, though the two can co-occur).

• “These ‘devilish incidents’ are most certainly not coincidences. Collisions in the street are obviously intentional. The fact that the soap is now on the table and was not there before is obvi- ously an insult.” [14]

• “These animals [referring to insects appearing in a garden] al- ways appear on definite occasions and in definite order around me… They cannot possibly have existed before and only been driven into my company accidently.” [57]

5.12 All-Inclusive Self-Consciousness/Ontological “Paranoia”

The subject has a pervasive sense of being watched. This has a distinctly ontological or cosmic quality, as though constantly being observed by some indefinable but ever-present (and usually critical) other or awareness. NB: This item can be similar to, or occur alongside, 3.4.2, Feelings of social paranoia or social anxiety*, or 6.10, Feelings of centrality, and may be queried in con- junction with these.

I had

a tremendous feeling of claustrophobia. I felt trapped. It was all

like a story.” [33]

• “It feels like the universe is zoned in on me.” [25] (also score 5.14.2, Self-referentiality)

• “I kept thinking I was being watched by videocameras

Sass/Pienkos/Škodlar/Stanghellini/Fuchs/

Parnas/Jones

132.239.1.231 - 3/10/2017 3:39:00 AM

Univ. of California San Diego

Downloaded by:

5.13 Diminished Ontological Independence of Experienced World/Subjectivism

The external world or a part thereof seems to lack in- dependent existence in some way, often feeling abnor- mally dependent on or restricted to the perspective or mental state of the subject.

5.13.1 Subjectivism/Solipsism ( = EASE 5.3 )

The subject feels as though objects or people lack inde- pendent existence, as if they were somehow expressions of himself or relied on him for their very existence, or as if only the subject’s own experiential field really existed. The subject may feel as though he has somehow created or lived everything that exists. This may co-exist with, or be- come confused with, a normal sense of reality that is in- dependent from the subject.

• “A patient had sometimes a fleeting feeling as if only objects in his visual field existed. Other people and places did not seem to exist. He immediately considered it as nonsense.” [2]

• “I seem to have lived all the events I have read about or heard about or knew by heart.” [18]

• “When I read a book or a newspaper, one thinks that the ideas in them are my own; when I play a song or an opera arrange- ment for the piano, one thinks that the text of the song or opera expresses my own feelings.” [57]

5.13.2 Double Bookkeeping

The subject is aware of two or more realities, but can distinguish between what is real (common-sense practical and social reality) and other domains (delusional or quasi- delusional) that have a less intersubjective, more private status. The subject may experience some things in an anomalous and idiosyncratic way, while still recognizing and responding to the common-sense constraints of real- ity.

• “My so-called delusions are concerned solely with God and the beyond, they can therefore never in any way influence my be- havior in any worldly matter…” [57]

• “Many of my aberrant pseudo-perceptions feel the way they do because I am actually perceiving them taking place in a parallel reality that only partially overlaps with this one.” [unpublished data]

• “I can feel absolutely certain that space and time (and hence physical reality) no longer or never did exist, and yet under- stand that in order to get to a psychiatry appointment I have to walk down the street, get on the train, and so …both ‘beliefs’ exist simultaneously and seem in no way to impinge on one another.” [unpublished data]

5.13.3 Influencing Physical Reality (= EASE 5.6)

The subject experiences unnatural forms of causation linked to her own inner subjectivity. External objects or

EAWE: Examination of Anomalous World Experience

events are experienced as changing in accord with the sub- ject’s experience or state of mind, as though the subject were somehow influencing them.

• He had the impression as if he could control the weather, as it seemed to change with his mood. [2]

5.13.4 Pseudomovements of Objects/Persons

(=BS C.2.3.7, = EASE 3.9) “Pseudo-movements of perceived objects and humans are experienced, especially when the subject is in motion himself. Therefore, he will often try to avoid moving. Ei- ther the subject or the object/human moves first, or both simultaneously, and the subject feels as if there is a strange link between the two .” [2] NB: In contrast to 3.7.9 Experi- ence of being imitated, this subtype typically involves no sense of being intentionally mimicked or mirrored. Both subtypes can occur together however.

• “You only see a still picture if you don’t move your head and eyes.” [17]

• “The flowers at the window suddenly started to shake, the land- scape to move heavily. The walls went back and forth.” [1]

5.14 Revelatory or Pseudorevelatory (Apophanous) Mood

Things seem to have an indescribable quality of dis- tinctness, peculiarity, or specialness; the world may feel full of uncanny meaning, of mysterious meaningfulness. Despite these feelings, the subject may be unable to grasp or specify exactly what the change is or might mean. NB: If combined with a distinct sense of immi- nence, of something just about to happen, also code 2.4.1, Perceptual anticipation.

5.14.1 Uncanny Particularity

Details of objects in the world appear to have a quality of ineffable specificity, peculiarity, particularity, or exact- ness, which seems to signify something, though it is nothing the person can identify.

• “The house-signs are crooked, the streets look suspicious; ev- erything happens so quickly. The dog scratches oddly at the door. ‘I noticed particularly’ is the constant remark these pa- tients make, though they cannot say why they take such par- ticular note of things nor what it is they suspect.” [14]

5.14.2 Self-Referentiality ( BS C.1.17, = EASE 5.1 )

The subject experiences mundane objects or events, or people, as being related to or directed at her in unusual ways; the interviewer should note if this seems likely to be “explained or mediated by a preexisting paranoid atti-

Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

41

Univ. of California San Diego 132.239.1.231 - 3/10/2017 3:39:00 AM

Downloaded by:

tude, feelings of insufficiency, preceding panic attack or depressive guilt” [2], since this might alter the nature of the experience.

• “When he was having a cup of coffee, he thought that the clouds resembled a man having a cup of coffee.” [2]

5.14.2.a Paranoid Significance * The subject believes that something signifies that oth- ers are trying to do him harm in some way.

• “It was as if everything was being done to spite me; everything that happened in Mannheim happened in order to take it out of me.” [14]

5.14.2.b Grandiose Significance The subject believes that something signifies her supe- rior importance, for example, as the “chosen one,” “di- vine,” possessed of special knowledge, or as being the fa- vored audience.

• “A young man noticed that other passengers in the train would occasionally cross their legs. Whenever this happened he knew that the whole scene around him was a play performed for his benefit.” [33] (also score 5.1.4, Falseness)

5.14.2.c Metaphysical Significance The subject believes that something implicates an over- all change in the very fabric of the universe, such as the coming “end of the world,” the “illusory” or merely “vir- tual” nature of everything, or some other metaphysical meaning. He is somehow personally implicated in the change, or else is singled out as receiver of the metaphys- ical revelation.

5.14.2.d Unknown/Unstatable Significance Object or event has a special meaning for the subject, but she is unable to say what it is.

• “It isn’t just that things seem different or changed but that there seems to be some intention or motivation behind the changes. Things seem to have transformed themselves or been trans- formed for a reason. And somehow – although I can’t figure out why – this seems to pertain directly to me.” [unpublished data]

5.14.3 Unspecifiable Strangeness The overall quality of the world seems changed in a way that is difficult to specify but has an uncanny, peculiar, or suspicious tone (which does not suggest uncanny particular- ity or self-referentiality). Often the subject will feel com- pelled to seek explanations for these changes – as if every- thing were enveloped “with a subtle, pervasive and strange- ly uncertain light.” [14]

42 Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

• “Something is happening, please tell me what it is.” [14]

• “Something is going on, as if some drama is unfolding.” [28]

• “Everything was the same and yet it seemed strange.” [47]

5.15 Quasi-Mystical Experiences

Subject struck by a sense of unity or the sheer existence of the world; this may have a mood-like quality.

5.15.1 Mystic Union with the World*

The subject feels a deep sense of union with the rest of the world. This involves not so much feelings of confused boundaries between self and world (i.e., 1.17, Loss of boundaries with, or demarcation from, the physical world), but rather a profound sense or even appreciation of being embedded in, coextensive with, or identical in sub- stance with the external world. NB: If applies only to oth- er people, score instead 3.7.6, Universal merging with others*.

• “In my mental illness I had been, as a person, enlarged and stretched beyond all reasonable limits. I was a part of every- thing, and the whole world, sometimes the whole universe, was in a sense a part of me.” [22]

5.15.2 Mere Being

Preoccupation with, focus on, or amazement at the sheer existence of objects or the world, with mere existence felt or thought to be far more significant than standard significance or “essence.”

• “When, for example, I looked at a chair or a jug…they became ‘things’ and began to take on life, to exist…Their life consisted uniquely in the fact that they were there, in their existence it- self.” [18]

5.16 Experiences of the End of the World

A feeling that the world is being destroyed or coming to a catastrophic end, or that this is about to happen. Can be associated with certain sensorial perceptions, and the subject may sometimes believe he himself is somehow responsible for this event (and may be the only one who will experience it).

• “I hear the world blowing up.” [29]

• “I sometimes feel absolutely strongly that the world is going to come to an end, that everything’s going to end. But not because I know how or why – there’s no specific vision there – just an impending sense of a final end to all things.” [unpublished data]

5.17 Anomalies of Mood or Affect

The subject experiences certain pervasive and mood- like anomalies in the affective or emotional feel of the

Sass/Pienkos/Škodlar/Stanghellini/Fuchs/

Parnas/Jones

132.239.1.231 - 3/10/2017 3:39:00 AM

Univ. of California San Diego

Downloaded by:

world, which may be accompanied by difficulty in per- ceiving, apprehending, or expressing normal emotions. Though often described in terms of internal states, typ- ically these moods also involve alterations in feelings about or the experience of the world as a whole. NB:

Generally, these experiences seem to differ from tar- geted, world-directed emotions bound up with normal human concerns; instead they involve omnipresent ex- istential anxiety or ontological amazement, for exam- ple.

5.17.1 Emptiness, Numbness, Indifference, Lack of

Spontaneous Response to the World * ( BS A.6.3 ) The subject describes feeling empty and numb, lack- ing strong and spontaneous responses to life events or the world, and being unable to respond emotionally or experience pleasure. She may describe herself as “cal- lous” or as experiencing “hardenings of her feelings” [50] and may experience herself or her own behavior as profoundly inauthentic. This may be evaluated nega- tively (e.g. shame or nostalgic sense of loss), positively (sense of superiority), or neutrally. Can be associated with an inability to prioritize or decide on the basis of emotional response.

• “I try to hold on to a certain emotion, grab it before it gets away. I think others are more spontaneous in this, it comes to them more freely and stronger.” [63]

• “I am without emotions or joy. All the time, I am in the same mood, that is, in a no mood, without swings or changes. It is total boredom. I only vegetate.” [unpublished data]

• “Immediate clear emotional significance seems to have disap- peared and consequently I often feel confused and at a loss as to how to respond to people and events.” [unpublished data] (also score 5.7.3, World experienced as incoherent, disorient- ed)

• “I am starting to feel pretty numb about everything because I am becoming an object and objects don’t have feelings.” [12]

5.17.2 Feeling of Emotional/Affective Blockage* (in

the sense of being unable to express) In contrast to the emotional numbness of 5.17.1, here the subject feels full of emotional or affective tension or ir- ritation, but blocked or even frozen within, without ability or strategy to express the felt tension.

• “Sometimes I feel completely blocked, as if paralyzed and I can- not express any emotion, negative or positive.” [unpublished data]

• “Sometimes I feel angry or very upset and desperate, but cannot express it, cannot communicate it at all. I just stare at my psy- chiatrist and am completely unable to convey anything other than a kind of blankness.” [unpublished data]

• “It’s like an internal block, a block of feelings.” [43]

EAWE: Examination of Anomalous World Experience

5.17.3 Pervasive, Nameless Anxiety with Fear of

Annihilation* (= EASE 2.14) The subject experiences a profound, all-embracing, or “ontological” anxiety in his encounters with the world, though this typically lacks a specific object or source and cannot be readily verbalized or named. It can be accom- panied by a fear of annihilation, of disappearing, or of dying.

• “I constantly live in fear. I cannot relax and I don’t know why.” [unpublished data]

• “Underneath all my fears is a fear of death, fear of not existing at all.” [unpublished data]

5.17.4 Basic Irritation, Restlessness, Anger

( Nonemotional Dysphoria ) * The subject experiences profound, inexpressible irrita- tion and restlessness in his interactions with the world, which cannot be adequately communicated – sometimes experienced as deep anger or distress.

• “Since I remember I felt a deep irritation: ubiquitous, powerful and irresistible.” [unpublished data]

• “Restlessness deep down within me provoked a huge gap be- tween me and other people. If only I could feel an emotion like love, hate or anything! Because emotions mean that you are part of a society, with this restlessness I was not.” [unpublished data]

• “…kind of an internal restlessness or mental irritation… al- most physically unbearable, [but] definitely in my mind, a ”

mental thing

[unpublished data]

5.17.5 Detached Euphoria

The subject experiences a nonemotional (not directed toward anyone or anything in particular) sense of elation or euphoria. In contrast to most instances of manic eu- phoria, this mood state typically has a cold, detached, or serene quality (not action-oriented or frenetic).

• “I’ve had some strange experiences like travelling in time and

flying to the planet Mars in which the feeling was unlike any-

of the deep beauty of the uni-

verse, and also, in those moments, the sense that I understood things in a deeper way.” [unpublished data]

thing I’d ever experienced

kind

5.17.6 Despair, Demoralization, Hopelessness*

( BS A.6.1 ) The subject finds himself in despair, demoralized, or desperate in his dealings with the world. This may be due

to feeling unable to interact with others and lead any kind of normal life, and may involve feelings of entrap- ment or hopelessness, or seeking refuge in the idea of suicide.

Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

43

Univ. of California San Diego 132.239.1.231 - 3/10/2017 3:39:00 AM

Downloaded by:

• “My afflictions fill the place that was meant for sharing love. I am crying in despair.” [64]

• “The world is a hostile and cold place in which we are sentenced to loneliness, estrangement, and finally death.” [65]

5.17.7 Abnormalities of Mood Constancy*.

5.17.7.a Mood or Emotion Is Abnormally Persistent* Mood or emotion is perhaps “lagging behind” changes in thoughts or circumstances.

• “There have been times when my emotions… are stuck, even though I’ve moved on and am in a new situation…Somehow the mood is still there, in a strange way…Just there just as an emotion without anything really attached to it.” [unpublished data]

5.17.7.b Mood or Emotion Is Abnormally Labile* Mood is prone to sudden shifts without reason or tran- sition. The subject “often jumps from one affect to an- other,” e.g., moving in an instant from intense agitation “to an exaggeratedly erotic, happy mood, only to become tearful and sad a few minutes later.” [50]

5.17.8 Incongruity of Mood or Emotion

5.17.8.a Mood or Emotion Inappropriate to the Current Situation Somehow mood ‘does not fit with’ the current thoughts or situation (other than those, involving indifference, that

are captured in 5.17.1, Emptiness, numbness, indiffer- ence, lack of spontaneous response to the world*) – e.g., inappropriate sadness when confronted with a happy event, or vice versa.

5.17.8.b Moods or Emotions Are Mutually Contradictory In what is felt to be an incongruous, often disconcert- ing fashion: “affective ambivalence” [50], a coexistence or simultaneity of opposed and/or conflicting feelings or emotions, presumably distinct from normal ambivalence of feelings.

“I see it as that I experience opposites simultaneously. Like if I read the word ‘white,’ I have to think black. But it’s also like that with feelings, so I might feel aroused and disgusted, inter- ”

[unpublished

ested and uninterested, that sort of thing data]

6 Existential Orientation

General Description. The 11 items in Domain 6 refer to an unusual ongoing orientation or a “fundamental reorientation” of the person’s “general metaphysical

44 Psychopathology 2017;50:10–54 DOI: 10.1159/000454928

worldview and/or hierarchy of values, projects, and in- terests” [2]. The anomalies at issue here are manifest as attitudes, opinions, or existential orientations. Items from EASE Domain 5 are included here when they clear- ly involve not primarily general impressions regarding how the world seems to the subject, but attitudes or in- terpretations concerning the world or one’s relationship to it. (These can certainly overlap: see, e.g., item 6.4, Absolute certitude, and also 6.2.2, Conceptual freedom/ anything goes.) Questions in this domain can intersect with issues previously discussed in the interview. How- ever, if the interviewer is unsure about the presence or absence of a Domain 6 phenomenon, it should be que- ried. It may be useful to obtain further information by ask- ing follow-up questions whenever the patient has en- dorsed an “existential orientation” item. (NB: Though relevant across the EAWE, this issue is particularly salient in this section.) These questions might include:

Could you say how long, also how consistently, you have had these feelings of … (the interviewer specifies the feeling/attitude in question)? Have you had them for as long as you can remember? Constantly or intermittently? Did they begin only after you began to have other unusual experiences involving perception, thought or feelings – or do they perhaps occur …only in the presence of such other, unusual experi- ences? …only after you had begun taking psychiatric medica- tions or other kinds of drugs? …only after some highly significant or perhaps difficult experience or other change in your life circumstances?

6.1 Rejection of Society or Convention

The subject rejects or declines generally accepted social values or participation in normal human society, choos- ing to live according to his own idiosyncratic values or ways of behaving. This is often experienced as having a largely volitional element; it is not primarily due to low or high mood, or low self-esteem. This may be associ- ated with feelings of social incompetence or fear of los- ing one’s identity or originality if one were to identify too closely with others or conform to society.

6.1.1 Disinclination for Human Society (BS A.6.4) The subject consciously rejects normal human society and may instead live as a loner or social misfit.

• “What I detest more than anything else is being persuaded by others.” [41]

Sass/Pienkos/Škodlar/Stanghellini/Fuchs/

Parnas/Jones

132.239.1.231 - 3/10/2017 3:39:00 AM

Univ. of California San Diego

Downloaded by:

• “I’m changed. I’m getting to be more humane. Will it ruin my brain? All this humanity is upsetting my own special frame- work. It’s polluting me.” [41]

• “I cannot reach them [other people], but also I don’t want to reach them.” [41]

6.1.2 Antagonomia

The subject acts in a way that runs contrary to social norms, not only disregarding rules and values but acting in a way that directly opposes them, often with repugnance, skepticism, or disdain toward convention or what is typ- ically taken for granted.

• “My aversion to common sense is stronger than my instinct to survive. That’s why I say that being against common sense is both a gift and a punishment at the same time.” [41]

6.1.3 Idionomia

The subject manifests a feeling of radical uniqueness and exceptionality with respect to common sense and a strong sense of fidelity to her own individuality or eccen- tric stance.

• “Madness is necessary to human intelligence to get to the high- er levels.” [41]

• “Doctor, I have a mission to accomplish. First of all, to build my country, Somalia, then together with my brother to build a more livable and fraternal world. I realized that there is a new culture in the world, tomorrow’s world, that of brotherhood.” [41] (also score 6.5.2, Messianic duty*)

• “I have the invention in my head. Mine is not an illness, it is an experiment. I was chosen for this. Something extremely impor- tant.” [41] (also score 6.5.2, Messianic duty*)

6.2 Extreme Indifference or Openness

The subject shows a highly unusual acceptance of or openness (regarding values or ideas) to a wider-than- normal variety of possibilities, suggesting detachment from normal concerns or common sense.

6.2.1 Attitude of Indifference, Insouciance, Lack of

Concern The subject reports an attitude or stance of extreme indifference regarding experience; nothing really matters (“schizophrenic insouciance” [37] and “je-m’en-fichisme” [not giving a damn] with “callous indifference” [50]). This indifference seems to have a detached or casual qual- ity, distinct from a depressed inability to care or the un- discriminating enthusiasm of mania.

• “I am an existentialist, everything is the same to me, I don’t need any diploma. The existentialists are people for whom ev- erything is equal.” [37]

EAWE: Examination of Anomalous World Experience

6.2.2 Conceptual Freedom/Anything Goes The subject feels as though she is more open to possi- bilities of interpretation or understanding than others are, often in ways that can disrupt conventional action, deci- sion-making, or conceptual grasp. NB: In contrast to 2.4.3, Feeling that “anything could happen,” the focus here is on possibilities of interpretation, not on unpre- dictability in the temporal flow (though the two can co- occur). NB: Consider also 6.3, Pervasive disbelief, skepti- cism, curiosity re the obvious/taken-for-granted. If ac- companied by experience of proliferating meanings, also score 5.8.3, Proliferation of meanings from the object.

• “If I no longer believe in gravity, it’s not that I fail to anticipate something when I don’t expect an apple to drop from the tree, but that I simply think that the apple could just as easily float or fly and therefore have no reason to anticipate it falling.” [unpublished data]

• “[A] patient had difficulty coming up with what is usually deemed the ‘correct response’ [to a picture arrangement test] because, as he said, ‘any order would make sense.’” [22]

• One patient would “collapse any difference of degrees of prob- ability,” since it is possible for historical archives to be tampered with (even if highly unlikely on a large scale); he insisted that one could not trust any historical account at all. [22] (also score 6.3, Pervasive disbelief, skepticism, curiosity re the obvious/ taken-for-granted)

6.3 Pervasive Disbelief, Skepticism, or Curiosity re the

Obvious/Taken-for-Granted (EASE 2.12)

Persistent and inescapable disbelief in, or doubtful cu- riosity about, things that most people simply take for granted as obvious and true (e.g., social conventions or fundamental assumptions about the world – such as the existence of gravity). This may be linked to other pat- terns of thought or behavior, such as needing to figure out the “true” nature of time, life, or the universe. NB:

Consider also 6.2.2, Conceptual freedom/anything goes.

• “I wonder sometimes where does this globe end. I look around and I wonder whether I can reach the end.” [unpublished data]

• “Sometimes I think about where did the first word come from? Who brought the first words, and where did it come from? I don’t understand how we have seeds, you know? Where did the seeds come from?” [unpublished data]

• “I doubt everything and everybody. Sometimes I even doubt that my parents are my parents or that Ljubljana is the capital of Slovenia.” [unpublished data]

6.4 Absolute Certitude

Patient experiences a sense of utter certitude about anomalous interpretations of the world, as if everything were already as clear and certain as 2 + 2 = 4: evidence

Psychopathol