Disorders of self

DISORDERS OF SELF
DR.R.G.ENOCH
MD Psychiatry I Yr
GMKMCH, Salem

• Self
• Terms
• Ego and self
• Self awareness
• Levels of self awareness
• Self concept and body image
• Theories
• Formal characeteristics of self
• Disorders

• Self-representation is central to human
behavior in health and disease.
• Specifically, people's capacities for recognizing
themselves as distinctly themselves and for
acquiring and acting on various kinds of self-
knowledge are critical
i. to regulate their behavior and
ii. engage in social interaction and social
relationships.

HISTORY
• During the Middle Ages emphasis was placed on
the concept of community rather than on self in
all aspects of social life.
• The significance of the community tended to
overshadow the significance of individuals and
their personal interests, which were viewed as
“selfish.”
• During the 18th century the individual, personal
identity, and personal expression became
increasingly valued.

 The widespread availability of
mirrors provided with a stable and
accurate representation of their
own faces, which encouraged
greater self-inspection, including
more frequent introspection
 Self psychology, a
modern psychoanalytic theory and
its clinical applications, was
conceived by Heinz Kohut in
Chicago in the 1960s, and is still
developing as a contemporary form
of psychoanalytic treatment

SELF
• In psychology, the self is defined as the way a
person thinks about and views his or her traits,
beliefs, and purpose within the world.
• collection of cognitively held beliefs that a
person possesses about themselves
• the evaluation by oneself of one's worth as an
individual in distinction from one's
interpersonal or social roles

TERMS
• Many different terms are used to describe the
way a person conceptualizes himself.
• Various terms used are body schema, body
concept, body cathexis, body image and perceived
body.
• Self-concept - fully conscious and abstract
awareness of oneself
• Body image - unconscious and physical matters,
includes experiential aspects of body awareness.

• The body schema implies a spatial element
and is usually bigger than, the body itself.
• The body schema changes with changing
circumstances. Eg. Spectacles, a cigar, the
carpenter’s screwdriver, the blind man’s stick.
• Cathexis - the notion of power, force, libido –
analogous to electrical charge: the self that
makes things happen!

SELF AWARENESS
• “The capacity to become the object of one's own
attention” (Morin, 2006).
• “...knowledge of oneself as a defined entity,
independent of other individuals...” (Legrain et al.,
2010).
• In German literature ego consciousness is called as
Ichbewusstsein
• It is now replaced by self- experience or self
awareness

Neisser's levels of self-awareness
The
ecological
self
the
interpersonal
self
the extended self
the private self
the conceptual self

Neisser's levels of self-awareness
1. The ecological self (Awareness of internal or
external stimuli) - self in the embodied form
that can be physically identified in time and
space
2. the interpersonal self (Awareness of
interactions with others) - the self which
exists in the social relations when we interact
with others

3. the extended self (Awareness of time: past
and/or future) - self which is in our memory,
is personal and private.
4. the private self (Awareness of owns own
thoughts, feelings, intentions)
5. the conceptual self (Awareness of ones own
self-awareness, possession of an abstract
model of oneself) - the idea of self that a
person holds

Implicit and explicit self-awareness
Implicit self-awareness:
 The self as “I”.
 The self is the “subject of experience”.
Explicit self-awareness:
 A mental representation of “me”.
 The self is the object of one’s attention.

EGO AND SELF
• Ego and self are used more or less
interchangeably
• Freud (1933) described ego as standing ‘for
reason and good sense while the id stands for
the untamed passions’.
• The three tyrannical masters of the ego are
the external world, the super-ego and the id.

• According to Freud's model
of the psyche, the id is the
primitive and instinctual
part of the mind that
contains sexual and
aggressive drives and
hidden memories,
• the super-ego operates as
a moral conscience, and
• the ego is the realistic part
that mediates between the
desires of the id and
the super-ego.

Self Concept
• Baumeister (1999) :
"The individual's belief about himself or herself, including
the person's attributes and who and what the self is".
• Self-concept is a knowledge representation that contains
knowledge about us, about our personality traits,
physical characteristics, abilities, values, goals, and roles,
as well as the knowledge that we exist as individuals.
• Throughout childhood and adolescence, the self-concept
becomes more abstract and complex and is organized
into a variety of cognitive aspects of the self, known
as self-schemas.

• Lewis (1990) suggests that development of a
concept of self has two aspect.
(1) The Existential Self
• the sense of being separate and distinct from
others and the awareness of the constancy of
the self' (Bee, 1992).
• It begins as young as two to three months old
and arises in part due to the relation the child
has with the world.

(2) The Categorical Self
• the child next becomes aware that he or she is
also an object in the world.
• Just like other objects including people have
properties that can be experienced (big, small,
red, smooth and so on) so the child is becoming
aware of him or her self as an object which can
be experienced and which has properties.

Self-Esteem
• Self-esteem refers to the positive or negative feelings that we
have about ourselves.
• We experience high self-esteem when we believe that we are
good and worthy and low self-esteem when we believe that
we are inadequate and less worthy than others.
• Self-esteem is in part a trait that is stable over time,
with some people having relatively high self-esteem and
others having lower self-esteem.
• But self-esteem is also a state that varies day to day and even
hour to hour.
• One common self-report measure of self-esteem is the
Rosenberg Self-Esteem Scale

Ideal Self
• what you'd like to be
• If there is a mismatch between how we see yourself (e.g.,
your self-image) and what we’d like to be (e.g., your ideal-self
) then this is likely to affect how much you value yourself.
• A person’s ideal self may not be consistent with what actually
happens in life and experiences of the person. This is called
incongruence.
• Where a person’s ideal self and actual experience are
consistent or very similar, a state of congruence exists.

THEORIES OF SELF
Self-awareness theory (Duval & Wicklund, 1972)
• when we focus our attention on ourselves, we tend to
compare our current behavior against our internal
standards.
Self-discrepancy theory (Higgins, Klein, & Strauman,
1987)
• states that when we perceive a discrepancy between
our actual and ideal selves, this is distressing to us. In
contrast, on the occasions when we feel that
we are being congruent with our standards, then it
produces a positive affect.

Self-affirmation theory
• people will try to reduce the threat to their self-concept
posed by feelings of self-discrepancy by focusing on
another domain, unrelated to the issue at hand.
• Eg. the person who has become addicted to an illegal
substance may choose to focus on healthy eating and
exercise regimes as a way of reducing the dissonance
created by the drug use.
Self-verification theory (Swann, 1983)
• people often seek confirmation of their self-concept,
whether it is positive or negative . This sets up a
fascinating clash between our need to self-enhance
against our need to be realistic in our views of ourselves.

SELF CONCEPT AND BODY IMAGE
• The body is unique in that it is experienced by a person both
as
 subject of experience and as an
 object with the same materiality as any other physical object
in the world.
• For most of the time, we are not aware of our body
• In times of distress or pain we become aware of our bodies as
distinct from ‘ourselves’.
• In extreme anxiety, traumatic pain and sexual excitement,
there is an awareness of the body as an object: ‘my heart
banging, my finger throbbing’.

AWARENESS OF THE BODY
 We have an awareness of our self and an awareness of our
bodies, which overlaps but slightly different.
 According to Head and Holmes (1911), the body schema is
formed as the composite experience of sensations.
 Freud also was concerned with body image in the
development of personality: ‘the ego is firstly the body ego’.
 Clearly, abnormality of body image may be the result of
abnormal sensations, but this is not always so.

• In an amputee – the abnormality of body image is directly
because of the physical damage
• a hypochondriacal patient may have no abnormal sensations
yet believes he has cancer.
• In transsexualism, a man may have a normal sensory
experience of his body but he hates his body and especially
his penis; His disturbed body image is not a result of disturbed
sensation; there is a conflict between ego and body image.
• The body image can be altered through enhancement,
diminution (or ablation) or distortion. Eg. Clothing improves
the body image.

Biological Aspects
 Recent studies suggest that fluctuations in the neurotransmitter
serotonin play an important role in regulating our level of self-
esteem. Researchers associate high serotonin levels in the brain
with high self-esteem and social status and low serotonin levels
with low self-esteem and social status.
 Neuroimaging studies strongly implicate
a) the medial prefrontal cortex (ventral and dorsal),
b) cingulate gyrus (anterior and posterior),
c) precuneus and temporoparietal cortex in self-referential
processing
 Hallowell reports that one’s self-perception, in general, can be the
product of evolution.

 There are two portions of the brain found to have a large
importance on a person’s perception of self.
1. The temporoparietal junction - integrate sensory information
2. The extrastriate body area located in the lateral occipitotemporal
cortex - perception of embodiment
 Making moral decisions, much like other neural processes has a
clear biological basis.
 The anterior and medial prefrontal cortex and the superior
temporal sulcus are activated when people feel guilt, compassion,
or embarrassment.
 Guilt and passion activate the mesolimbic pathway, and
 indignation and disgust are activated by the amygdala.

SPLIT BRAIN STUDIES
• Complete transection of the corpus callosum for the treatment of
medically intractable epilepsy 1960s.
• Functional specializations of the two cerebral hemispheres were the most
widely reported findings of the initial studies - conducted by Roger Sperry
and for which he won a Nobel Prize in 1981.
• Besides these studies also showed a real-time separability of aspects of an
individual person's consciousness. Long-term observations of such
patients showed that each disconnected hemisphere possesses a
separate sensorimotor interface with the environment, with its own
perceptual, amnestic, and linguistic repertoires, and styles of decision-
making.
• ‘interacting’ with each of the separated hemispheres in individual patients
felt akin to interacting with a distinct personality.

FORMAL CHARACTERISTICS OF SELF
• Jasper, described self-awareness, that is, the ability
to distinguish I from not I, as having four formal
characteristics.
1. Ego activity
2. Ego consistency and coherence
3. Ego identity
4. Ego demarcation
• Scharfetter added a fifth dimension of
5. Ego vitality to the list.
• Previously, this characteristic was incorporated
within the egoactivity.

• Ego vitality - The feeling of awareness of being or
existing:
I know that I am alive and exist – this is fundamental
to awareness of self.
• Ego activity - The feeling of awareness of activity:
I know that I am an agent who initiates and executes
my thoughts and actions.
• Ego consistency and coherence - An awareness of
unity:
At any given moment, I know that I am one person.

• Ego identity - Awareness of identity:
There is continuity in my biography, gender,
genealogical origin, etc.;
I have been the same person all the time.
• Ego demarcation - Awareness of the
boundaries of self:
I am distinct from other things and can
distinguish what is myself from the outside
world, and I am aware of the boundary
between self and non-self.

• A number of symptoms of psychiatric illness
can be regarded as disturbances in two of
these aspects of self-experience:
1. awareness of existence and activity of the
self and (ego activity )
2. awareness of being separate from the
environment (ego demarcation)

DISORDERS OF SELF
• Abnormal inner experiences of I-ness and my-
ness that occur in psychiatric illness.
• Occur in the patient’s state of inner awareness
irrespective of any changes he may show in his
attitude towards the outside world.

Classification
• Disorders of Ego vitality
• Disorders of Ego activity
• Disorders of Ego consistency and coherence
• Disorders of Ego identity
• Disorders of Ego demarcation

1. DISORDER OF BEING OR EGO VITALITY
• Being: the patient’s experience of his very existence
may be altered:
• Eg :
‘I do not exist;
 there is nothing here’ or
‘I am not alive any more’ or
‘I am rotting’.
• This is the core experience of nihilistic
delusions, which may occur in affective psychoses.
• Less pronounced nihilistic ideas (not delusions) are
experienced as depersonalization, an alteration of the
way one experiences oneself, which is accompanied by
a feeling of an alteration or loss of significance for self

2. DISORDER OF ACTIVITY
• All events that can be brought into consciousness are
associated with a sense of personal possession. This ‘I’ quality
has been called personalisation (Jaspers, 1997) and may be
disturbed in psychological disorders.
 Memorizing and imagining may be changed in depression -
unable to initiate the act of memory or fantasy;
 Moving may show abnormality, for example in the passivity
experience or delusions of control of patients with
schizophrenia.
 Willing may be altered - schizophrenia pts no longer
experiences his will as being his own. Commonly, neurotic
patients describe an inability to initiate activity, a feeling of
powerlessness.

• Some of these abnormalities of experience of one’s
own activities are closely associated with mood,
• for example the feeling of the depressed patient who
believes that he is incapable of doing anything at all:
the alteration of self-concept is directly linked to the
mood state.
• Sometimes, however, it is not the affect associated
with the change of activity but the belief about the
initiation of the activity that is changed. These are
the passivity experiences

3. DISORDER OF EGO CONSISTENCY
• In health, a person is integrated in his thinking and
behaviour so that he is not aware of his feeling of unity.
• There is an assumption that he is one person, he knows
his limitations and capabilities. This assumption of
unity may be lost in some conditions.
• In dreams, one sometimes sees oneself, even perhaps
with some surprise, in the drama.
• In some forms of meditation, by carrying out repetitive
monotonous acts the subject enters a self-induced
trance in which he can observe himself carrying out the
behaviour.
• ‘Self ’ is both the observer and also the object of
observation.

A) AUTOSCOPY (heutoscopy /phantom mirror image)
1. feeling of presence,
2. negative autoscopy,
3. inner autoscopy,
4. autoscopic hallucination,
5. out of body experience,
6. heautoscopy proper
B) MULTIPLE PERSONALITY (DISSOCIATIVE IDENTITY
DISORDER)

A) AUTOSCOPY
autos (self) and skopeo (I am looking at)

1. Feeling of presence
• In the feeling of presence, the patient has a
distinct feeling of the physical presence of
another person.
• No visual perception is usually reported.
• The feeling of presence may be confined to
one hemispace when the experience occurs in
association with a seizure.

2. Negative autoscopy
• Negative heautoscopy
refers to the failure to
perceive one’s own
body either in a mirror
or when looked at
directly. This
phenomenon is often
associated with
depersonalization.

3. Inner autoscopy
• Inner heautoscopy
refers to the
experience of visual
hallucinations of
internal organs in
extra-corporeal
space

Autoscopic hallucination – seeing your double
but the view point is still from your own body
Heautoscopy – seeing your double but not
sure where you are located
OBE – seeing your double but the view point
is from your double. Supine position.

4. Autoscopic hallucination
• Autoscopic hallucination is said to occur when a patient
sees an exact mirror image of himself, or of his face or
trunk.
• The view point is from the body.
• These are usually brief, lasting seconds to minutes and
followed by flash-like recurrences.
• Also referred to as external autoscopic hallucination,
specular hallucination, mirror hallucination,
deuteroscopic hallucination, and visual phantom double.

5. Out of body experiences
• Out of body experiences are characterized by the
projection of an observing (psychological) self in
extra-personal space seemingly totally
dissociated from the physical body.
• In this phenomenon, the patient sees himself
and the world from a location distinct from his
physical body.

• There are three
phenomenological
characteristics here:
1. disembodiment,
2. the impression of seeing
the body from a distant
and elevated visuo-
spatial perspective (the
so-called extra-corporeal
egocentric perspective)
and
3. the impression of seeing
one’s own body from this
elevated position

NEAR DEATH EXPERIENCE
• These experiences are
reported when an individual
comes near to death and
survives.
• Ring identified a five stage
model which most NDEs go
through:
• (i) Deep peace and a sense
of well-being
• (ii) Separation from the
body: either a
disconnection from their
body and looking down on
their body from above.

• (iii) Entering the darkness: sense of travelling
through a dark space or tunnel. There may also be a
life review at this stage, or meeting dead or loved
ones, or a decision to return or go on.
• (iv) Seeing the light: some individuals moved straight
into a brilliant light.
• (v) Enters the light: this is reported as a world of
exceptional beauty.

6. Heautosocpy proper
• Heautoscopy proper designates a condition in which
an individual sees his double or doppelgänger.
• The view point is doubtful. The double usually appears
colourless, can behave independently, and may or may
not mirror the patient’s appearance.
• Experience of existing at and perceiving the world
from two places at the same time.

• There may be vestibular
sensations such as extreme
lightness of the body,
sensation of flying,
elevation, rotation and
vertigo
• There is a North European
myth, shared by several
countries, that someone
may see his double
(‘wraith’, ‘fetch’) shortly
before his death.

• Can occur in association with seizures.
• there is a failure of integration of proprioceptive, tactile
and visual information about the body accompanied by
vestibular dysfunction.
• the multimodal junctions between the parietal and
temporal lobes and between the parietal and occipital
lobes have been implicated.
• the left posterior insular is involved in heautoscopy and
right occipital cortex in autoscopic hallucination.
• Experimentaly application of transmagnetic stimulation
of the left temporoparietal junction produce
heautoscopy (doppelganger)

 A bizarre example of autoscopy was reported by Ames
(1984): the self-shooting of a phantom head.
• This patient was suffering from schizophrenia.
• He described himself as having two heads
• believed that the other head was actually that of his wife’s
gynaecologist , whom he believed to be having an affair with
her
• He described seeing and hearing the voice of gynaecologist
from another head
• The patient tried to remove the other head by shooting six
shots at it through his own palate, causing extensive damage
to his brain.
• Ames labelled this condition the ‘phenomenon of perceptual
delusional bicephaly’.

B) MULTIPLE PERSONALITY
(DISSOCIATIVE IDENTITY DISORDER)
• In dissociative (hysterical) states, so-called dual and multiple
personalities have been described
• The essence of multiple personality is the embodiment of at least
two personalities (identities).
• This phenomenon raises doubts about our natural intuition that an
individual human being is indivisible and is an embodied singular
person.
• In MPD the personality may change from time to time, often from
hour to hour, and with each change the character becomes
transformed and memories altered.
• The different personalities although making use of the same body,
each nevertheless, has distinctly different character: a difference
manifested by different trains of thought, by different views, and
temperament, and by different acquisitive tastes, habits,
experiences, and memories.

• Larmore et al. (1977) described ‘a 35-year-old white
woman of rural Kentucky background’
• She made seven suicide attempts, which she had no
memory.
• In hypnotic interview she had 4 distinct personalities
 The primary personality
 Faith
 Alicia
 Guardian Angel
• Alicia is ‘a Satanic agent … claims control over most
of her physiological functions … manifesting as either
assaultive or self-destructive behaviour’;

Abse states that ‘one-way amnesia’ is usual for multiple
personality; that is,
 personality A is amnesic for the other personality B,
 but the second, B, can discuss the experiences of A.
 Usually, A is inhibited and depressed and B is freer and
more elated.
The forms of multiple personality seen in practice are
usually:
 simultaneous partial personalities
 successive well-defined partial personalities
 clustered multiple partial personalities.

Lability in the Awareness of Personality
• Described by Bonhoeffer (1907) as occurring in paranoid
psychosis.
• The loss of unity of self in schizophrenia was exemplified
by a patient who described how, every night, he became
a horse and trotted down Whitehall.
• At the same time as this was happening in his mind, he
also believed he was in Whitehall watching the horse.
• This type of symptom has been called lability in the
awareness of personality.

4. DISORDER OF IDENTITY
• I am who I was last week; I am who I will be next week or in
10 years’ time.
• This truism, is affected in schizophrenia or from organic states,
from neuroses or from depression, or even for some healthy
people in abnormal situations - possession state. This disorder
of self-awareness is characterized by changes in the identity
of self over time.
• A feeling of continuity for oneself and one’s role is a
fundamental assumption of life, without which competent
behaviour cannot take place.

• In health, we have no doubts about the continuity of
ourself from our past into our present.
• In schizophrenia the patient claims that at some time in
the past he has been completely changed from being one
person to another, whom he now is.
• The complete alteration in the sense of identity is
exclusively psychotic;
• There is a break in the sense of identity of self, and there
is a subjective experience of someone completely
different, ‘taking over’.

• A feeling of loss of continuity, which is, however, of lesser
intensity may be experienced in health and in neuroses
and personality disorders. This may occur following an
overwhelmingly important life situation or during
emotional development without an outside event. For
example, an adolescent may quite suddenly feel in the
course of a week ‘as if ’ he is quite a different person.
• the depressive, secondary to disorder of mood, often
sees no continuation into the future: ‘everything is bleak,
there is nothing to look forward to’.

POSSESSION STATE
• This is classified in ICD-10 under dissociative (conversion) disorders
(F44) – trance and possession disorders (F44.3).
• Although the trance or altered state of conscious awareness is a
prerequisite, possession state does not necessarily occur in the
context of dissociative or hysterical disorder.
• It can occur in normal, healthy people in unusual situations, either
as a group phenomenon (mass hypnosis) or individually.
• There is a temporary loss of both the sense of personal identity and
full awareness of the surroundings.
• The person acts as if he has, and believes himself to have been,
taken over by another – a spirit, a force, a deity or even another
person.

• The difference between those conditions that constitute
disorder and those that may be considered as being within a
religious context alone is that the former are
 unwanted,
 cause distress to the individual and those around
 may be prolonged beyond the immediate event or ceremony
at which it was induced.
 There is no self control
 social or functional impairment
• possession and trance states can occur in neurological disease
such as lesions in the basal ganglia and fronto-parietal lobes.

Lycanthropy
• Jaspers commented on the
rare condition of lycanthropy,
the patient believing that he
has been transformed into an
animal, literally a wolf.
• Lyncathropy includes an
identical beliefs of
transformation into other
feared animals such as the fox
in Japan, the tiger, hyena and
crocodile in China, Malaysia
and India are documented
(Fahy, 1989).

• The belief was identified as a delusion of non-specific
value but principally associated with mood disorders,
schizophrenia, and occasionally organic brain disease.
• a transient belief but occasionally the belief can be
enduring, lasting for many years.
• Jaspers differentiated between states of possession
presenting with an altered consciousness and states of
possession in which consciousness remains clear; the
former were usually dissociative (hysterical) in origin,
while the latter were more often associated with
schizophrenia

5. DISORDER OF EGO DEMARCATION
• One of the most fundamental of experiences is the difference
between one’s body and the rest of the world.
• this distinction is acquired in later life and that the young infant is
unable to differentiate between itself and the rest of the world.
• largely attributable to the function of the proprioceptive system.
• Disorder of the boundaries of the self refers to the disturbance in
knowing where I ends and not I begins.
• This can be readily demonstrated – anaesthesia of finger,
anaesthesia of lip
• For example, in LSD intoxication the feeling of impending ego
dissolution associated with the feeling of self ‘slipping way’ with
considerable anxiety has been described.

…disorder of egodemarcation
• In schizophrenia, the sense of invasion of self appears to
be fundamental to the nature of the condition as it is
experienced;
• There is a merging between self and not self
• The patient is not aware of the disturbance being one of
ego boundaries; he describes a problem only inasmuch
as ‘other people are doing things to me, events are taking
place outside myself ’.
• The external observer finds a blurring or loss of the
boundaries of self that is not apparent to the patient
himself.

…disorder of egodemarcation
• All passivity experiences are actually coming from inside
the self falsely attributed as coming from outside.
• The subjective experience of passivity is a disorder of the
distinction between what is and what is not self.
• This is also true for disorders of the possession of
thought, such as thought insertion and thought
withdrawal.
• For Auditory hallucinations, the patient ascribes the
internally generated activity, that is, internal speech, to
external agencies.

Other Alterations to Boundaries
• In states of ecstasy, there are also disturbances in the
boundaries of self. The participant might describe feeling at
one with the universe, experiencing unity with the saints,
identifying with the trees and flowers or a oneness with God.
• Ecstasy states occur in normal people and in those with
personality disorder, as well as in sufferers from psychoses
and in epilepsy.
• In epilepsy it is part of the aura and is characterized by intense
feelings of well-being and heightened self-awareness.
• It is thought to emanate from hyperactivation of the anterior
insula rather than the temporal lobe.
• In ecstasy, it is an as if experience, and it is mediated
affectively.

• A patient with schizophreia said, ‘I am invaded
day and night. I have no more privacy since
television came inside me’.
• Another patient believed that while he was in
a hospital ward he was helping other patients
because he permeated the medical staff and
thereby assisted them in their work.

In short,
• Disorders of Ego vitality – nihilistic delusions
• Disorders of Ego activity – passivity phenomenon
• Disorders of Ego consistency – autoscopy and
dissociative identity disorders
• Disorders of Ego identity – possession states and
lycanthropy
• Disorders of Ego demarcation – passivity, thought
insertion and broadcasting.

CONCLUSION
• The scientific investigation of means by which
nervous systems achieve self-representation is in its
relatively early stages.
• With fuller understanding of mechanisms supporting
self-representation in nervous systems, insights into
mechanisms causing or sustaining the disorders are
likely to be achieved as well.

References
• Sims symptoms in mind – 4th and 5th edition
• Fish’s Clinical Psychopathology - 3rd edition
• Kaplan and Sadocks Comprehensive textbook of Psychiatry –
10th edition
• Kaplan and Sadocks Synopsis of Psychiatry – 11th edition
• Principles of social psychology – 1st edition.

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