Self-disorders: A cause of poor insight in schizophrenia?

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I thought this article from the Schizophrenia Bulletin was interesting:

http://schizophreniabulletin.oxfordjour ... bt087.long

A lot of the experiences described here are similar to that I had in my psychotic episode at 14 and before and after it--note I was diagnosed with schizotypal personality disorder, which is on the schizophrenia spectrum. Some of the ones I noted were:

1.) Double ontological orientation. Even though I was psychotic as heck, even the day before I acted on my delusions, I was still able to conduct business with the world relatively normally.

2.) I definitely found my original delusional experience to be very felt, revelatory as well.

3.) Before and after the psychotic episode, I would become very wrapped up in fantasy, usually involving me as the chosen one to go on a Final Fantasy-like adventure. After the psychotic episode, I knew that my parents and mental health professionals knew that it was either delusions or delusion-like experiences that had led to my aberrant behavior at 14 that resulted in a long hospitalization, and when I fantasized I became somewhat anxious, worried that if they found out they'd lock me up again. I remember reading LOTR at 15 or 16 and my dad reminding me, "You know that's not real, right?" I knew exactly what he was referring to. Basically, as mentioned in the article, I did not see much difference between my fantasies and the delusions I developed at 14. As I've moved into my late 20s and my focus on gender transition increased, the fantasies have decreased.

4.) As mentioned in the article, at the time of my delusions, I knew that they could qualify as being symptomatic of schizophrenia or something similar, but I believed either that I chose to believe the delusions, like it was just a game, and that I didn't want to disturb anybody around me with describing them, or that I knew better, understood better than the people around me and so they could not be trusted with the truth.

That's all I can think of, for now. Would anyone else with a schizophrenia spectrum disorder, or heck any history of psychosis, care to share their story?

I was dx with "ideas of reference", See here, http://en.wikipedia.org/wiki/Ideas_of_r ... _reference

That is when your mind makes you think the ordinary things people do are done intentionally to hurt you, or make fun of you. You believe people are thinking negative thoughts about you, or if someone laughs, then you think they are laughing at you. If you are in the grocery isle, and it is slow, then people are intentionally slowing down the line to anger you.

At work at the time, my boss would ask me to do something, and my mind would think that he is intentionally assigning me those tasks cause they are so easy, and he hopes I will get bored and quit, or if they are hard, then he hopes I cannot do them, and quit because I failed to do them. My mind would think, he hates me, I disgust him, he wants me gone.

Also at work, someone was showing me a knife, and somehow I believed it to be an implied threat ,a threat that I am a sick , disturbed person, and should quit the job because I disgust this person. I believed it so strongly that I told my friends that I was threatened. I was wrecked after work with thoughts that I am a disgusting person, no one wants me to work there.

I wrote about it online on the company computer, and the owner of the company monitored my post, and sent out an email that the company would not tolerate threats.

I think self-hate leads to ideas of reference, also theory of mind might facilitate the development of the condition.

I've exhibited ideas of reference myself from time to time, as remarked upon by my therapist, but for some reason I can't think of any examples.

Well, there was that one time when I thought the meteor had a special message for me when I was 14, but that was more a delusion of reference.

EDIT: Also, before that delusion of reference, I felt like everybody was getting set up, like video game NPCs, for the apparent game that was about to start, that I was the star of. I guess those could be ideas of reference.

I identify most with the "double book keeping".

I am pretty convinced that I've at least schizotypal traits. I can identify with paranoid thoughts and even if I tell myself (and somehow know) this situation isn't that bad, it still doesn't really stop my paranoid thoughts. But I still know that it's kind of "crazy" and so usually don't talk about it. Somehow there is the "real" world and sometimes (not always) I've the feeling that there is also another world.

I would say that "poor insight" into the illness is one of the key symptoms of schizophrenia. But I don't think it's a poor insight in general, it's mainly related to the schizophrenic symptoms.

Ja. That's what makes the article in the OP so interesting. It looks at the context in which the poor insight occurs. Basically, the initial delusional or hallucinatory experience is "lived" or "felt," just like you would "feel a toothache"; often, the delusional or hallucinatory experiences don't seem all that different from the manifestations of the self-disorders themselves, like the tendencies to be wrapped up in fantasy, to experience Gedankenenteignung (not feeling like you own your thoughts), or to experience Gedankenlautwerden ("thoughts out loud"); the self-disorders throw the patient into a "solipsistic" world view where they feel like they are gaining great insight that others fail to grasp; and other contributing factors.

I just read the article halfway through, but I still want to read the other half.
I didn't know that in the english speaking world you also use the German words: "Gedankenlautwerden" and "Gedankenenteignung".

My own experience with psychiatrists is,that most don't recognize schizotypal symptoms if they aren't severe enough and try to explain it someway else, just when those symptoms get severe, they usually start recognizing them correctly. So in my opinion the awareness under psychiatrists for "mild" symptoms on the schizophrenic spectrum isn't big enough. At least not in my country, here the dx of "schizotypal PD" is very rare.

I think it has to do with the influence Germans have had on psychiatry, especially early on.



Ooh! I think you'll be interested in this article, then, too! They do a case vignette of a patient, and the structured interview suggests major depression, but the more thorough conversational interview, which is phenomenologically-based, suggests instead a schizophrenia spectrum disorder:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3668119/

If you look at the tables in the article, you can see the way each type of interview went.

EDIT: Note especially how the structured interview misses his thought insertion, because the blunt wording of the question makes it difficult for him to recognize his own experience in it, whereas the conversational interview was able to elicit that information.

Another problem is that I noticed when talking to ppl who had psychotic symptoms or just "mild" symptoms out of the schizophrenic spectrum, that very often they don't tell that other ppl, not even psychiatrist. At least not when they don't know them very well. The point is that they sometimes know that those thougts were "crazy" and so avoid talking about it, being afraid of that lable. Also that some patients -even with more severe symptoms- are sometimes still able to "double book keeping" explains that fact and might also be one of the reasons why schizophrenia spectrum disorders usually don't get dx early.

Now I read the entire article and I also see the problems in the structured psychiatric interview.
I also very often thought that they "missed" the imprtant questions, but many psychiatrists think that asking a fiew questions would be enough with no space for adding any personal thoughts. I especially noticed this behaviour in psychiatric clinics.

Now seeing many different psychiatrists since a fiew years (I moved and I also saw many different once in the psychiatry) I was asked just once(!) if there are any other family members with mental health problems.
I was also never(!) asked what I think why and when my symptoms started.

I'm very dissapointed in the way most psychiatrists make their structured interviews and also their diagnosis. Usually they had very fast a certain opinion and all the other symptoms were just stuffed into there, no matter if they really fit or not...
Not all of course, but I believe it's even the majority.

Raziel,

I would absolutely love to receive one of those phenomenologically-based interviews as mentioned in that study.

yes
my opinion is that the diagnostic interviews have to change in the long run anyway, because they don't seem to work that well with some symptoms/disorders.

I have a funny example how questions from a psychiatric interview can be understood...

A person I know in private works in the psychiatry and because it once happened to her while interviewing an old lady she told it as an example, of course without any name.

doctor: "do you sometimes hear voices from people who aren't there?"
old lady: "yes on the phone"
doctor: "do you sometimes see things that other people don't see?"
old lady: ... "I'm very good in finding lost items again."



That might be an extrem example, but I already heard twice that ppl missunderstood questions from psychiatric interviews, both were autistic by the way. I also don't come along with that method very well.

That's pretty funny.

I was reading this about double bookkeeping:

http://books.google.com/books?id=53nerz ... ia&f=false

It says that people with schizophrenia, though their delusions are still "incorrigible," are often much less "dogmatic" when it comes to their delusions than are fanatics and manic-depressives. It mentions how people with schizophrenia much less often act on their delusions and may even act in ways that seem to belie their delusional beliefs.

This reminds me of how I was in regards to my delusions, for a whole month and a half, I did virtually nothing with regards to them, and even continued acting in a "normal" way, even working on, for example, getting out of the special school I was in into a "normal" school. I remember at some points, though, noticing my own double bookkeeping, which I interpreted to be a lazy lack of devotion, and castigated myself for it, promising myself that I would be a bit more faithful.

I have high insight. I was told this by the person whose treating me, the psychiatrist. I've been seeing her for one year or more and she is very encouraging and empathetic. I also have most definitely a genetic form of schizophrenia with a mood disorder, which is called schizoaffective. It just means you have schizophrenia and a mood disorder I think. We had a long conversation about the difference between schizoaffective and bipolar with psychotic features among other things. She said that since you experience the symptoms independent of mood symptoms sometimes, but that mood symptoms are an issue, it's more schizoaffective because I also have had paranoid delusions etc. But my mood isn't the main cause of the illness. I do, however, have the Bipolar mood problem in addition to schizophrenia, which means that I am prone to mania. That's it. So I'm prone to mania or elation, euphoria, insomnia, etc. and depression for shorter periods of time. I am also prone to paranoia without taking medication. But schizoaffective is more treatable than schizophrenia alone, or that's her assumption. But I have been getting progressively better the more I treat the illness.

My first symptoms involved disconnectedness, racing thoughts, unreasonable beliefs. It evolved into a full blown scenario where i believed I playing an actress in movies or complex stories of different people. But I became disillusioned in boarding school when my odd behavior caused me to be teased a bit. I have always been intuitive and creative. The medication doesn't completely block the creativity but it keeps me from getting too creative lol. I have struggled with persecution delusions a few times in the past. Now I have high insight. I sometimes think I have paranoid schizophrenia, which is also fairly treatable. But, I don't think I have paranoia as a label to my knowledge because I do not have paranoia or delusions more than 2 percent of time, or like never. I am very rational and do not have strange beliefs. I'm kinda like Elyn Saks, a person who recovered--except I don't need to see a therapist 5 times a week, and I don't hold a PhD, though I could if I could afford it. I love psychology.

I know a bunch of people with the same label and where-as I can be talked out of a delusion or someone can prove its wrong, a lot of them hold on to their beliefs and I dont understand why. To them it's like religion to me, but I'm not even very religious either. I'm just spiritual. I do miss the high energy and intelligence though, that my manic states created.

I don't regret having schizophrenia, but I do regret that damage it has done to others and the limitations it caused, also the fact it has been a stressful thing which has impeded my would-be progress with education and work.

I've some thoughts were I do double bookkeeping, but I don't think I've schizophrenia, just certain traits. But it's a spectrum anyway...

Some are about ghosts or stuff like this. Not really religious, but "supernatural". But I was interested in all kind of religions. Somehow I belive in that stuff, but not like a fanatic. On the other hand I've clearly a paranoia/anxiety disorder, but that's more serious. I can't stopp it.
I talked with a friend about it today and she thinks it's clearly paranoia and somehow I even know that, but it still doesn't change the fact that no matter what you say, it doesn't stopp.




What did you think about your delusions back than?
I read somewere (sadly I forgot were), that even if schizophrenics are "cured" from a delusion or paranoia so that they know that it's not true, they usually keep their feeling about that situation.

Last edited by Raziel on 21 Dec 2013, 12:31 pm, edited 1 time in total.

Yes it is, because there is a spectrum between Bipolar and Schizophrenia and Schizoaffective is right in between.
So it is usually better treatable as Schizophrenia, but worse than Bipolar.

here is an interesting essay, also about double bookkeeping:

The Paradox Of Schizophrenia