Copyright Blackwell Munksgaard 2003

Acta Psychiatr Scand 2003: 108: 126133

Printed in UK. All rights reserved

ACTA PSYCHIATRICA
SCANDINAVICA
ISSN 0001-690X

Anomalies of subjective experience in

schizophrenia and psychotic bipolar illness
Parnas J, Handest P, Sbye D, Jansson L. Anomalies of subjective
experience in schizophrenia and psychotic bipolar illness.
Acta Psychiatr Scand 2003: 108: 126133. Blackwell Munksgaard
2003.
Objective: Contemporary psychopathology, as a result of
behaviourally dominated epistemological stance, downplays anomalies
of the patients subjectivity. This neglect has probably deleterious
consequences for research in the causes and the boundaries of the
schizophrenia spectrum conditions. The purpose of this study is to
explore frequency of qualitative, not-yet-psychotic, anomalies of
subjective experience in patients with residual schizophrenia and
psychotic bipolar illness in remission.
Method: The patients were examined with the Danish version of the
Bonn Scale for the Assessment of Basic Symptoms (BSABS).
Anomalies of experience were condensed into rational scales with good
internal consistencies.
Results: Diagnosis of schizophrenia was associated with elevated
scores on the scales measuring perplexity (loss of immediate meaning),
disorders of perception, disorders of self-awareness, and marginally so,
disorders of cognition.
Conclusion: These findings, in conjunction with those from other,
methodologically similar studies, suggest that certain anomalies of
subjective experience aggregate significantly in schizophrenia. These
experiential anomalies appear to be relevant for early differential
diagnosis and therefore potentially useful in the preonset detection
of the schizophrenia spectrum illness.

Introduction

A recent series of editorials in major journals (14)

has pointed to a dangerous decline of the science of
psychopathology, especially affecting research in
schizophrenia. In particular, studying the patients
subjectivity has become limited in scope and
methodology, because of unilateral concerns with
reliability issues (5). An instructive example here is
the construal of the negative schizophrenic symptoms as simple behavioural deficits a lack is
signalled here by the deprivative a, e.g. a-logia,
a-volition (6). Such account has transformed an
entire range of phenomena, previously regarded as
diagnostic trait indicators of the schizophrenia
spectrum disorders, into non-specific psychopathological features (2, 68). Most importantly, however, this construal fails to vindicate the patients
subjective perspective, often populated by appar126

J. Parnas1,2, P. Handest1,
D. Sbye3, L. Jansson1
1
Cognitive Research Unit, Copenhagen University
Department of Psychiatry, Hvidovre Hospital, Hvidovre,
Denmark, 2Danish National Research Foundation:
Center for Subjectivity Research, University of
Copenhagen, Copenhagen, Denmark, 3Institute of
Preventive Medicine, Copenhagen, Denmark

Key words: schizophrenia; bipolar illness; subjective

experience; self; basic symptoms
Josef Parnas, Danish National Research Foundation:
Center for Subjectivity Research, University of Copenhagen, Kbmagergade 46, 1150 Copenhagen K,
Denmark
E-mail: parnas@vip.cybercity.dk or parnas@cfs.ku.dk
Accepted for publication February 4, 2003

ently positive distortions of experience that resist

comprehension or description in pure deficit terms
(6, 912).
This lack of psychopathological resources to
address subjective experience is becoming strikingly visible thanks to the recent, worldwide explosion
of interest in early, prodromal detection of schizophrenia (13). These therapeutically oriented
programs have inadvertently revealed that psychopathology is short of descriptions of subtle, notyet-psychotic, anomalies of experience that might
be accurately efficient in identifying individuals at
risk of imminent psychosis (14). Behaviourally
defined negative symptoms of schizophrenia are for
that purpose prohibitively common in the general
population (7) and !behavioural deviations alone,
without exploring subjective experience, lack the
specificity necessary to predict future schizophrenia" (15, p. 962). In consequence, only intermittent

Experience in schizophrenics and bipolars

or low intensity (attenuated) psychotic features are
the symptoms at hand for predicting a future fullblown psychosis in first-contact clinical populations (14, see 16 and 17 as recent examples), a
predicament, which despite its pragmatic usefulness, is theoretically tautological.
Yet, non-trivial empirical evidence has in fact
been available for quite some time, demonstrating
that schizophrenia is frequently associated with
characteristic non-psychotic qualitative anomalies
of subjective experience, which may antedate
its onset. In the Anglophone psychiatry, it is
McGhie and Chapman (18) who are credited
with the first systematic and very detailed descriptions of such experiences, replicated in few other
studies (1921). Most recently these phenomena
were re-emphasized by a distinguished scholar of
schizophrenia, Paul Meehl, who proposed that
certain alterations of subjective self-experience
deserve, from a diagnostic perspective, to !be listed
along with signs such as Bleulers associative
loosening" (22, p. 190).
McGhie and Chapman identified, through
in-depth clinical interviews with first onset schizophrenic patients, subtle non-psychotic experiential
anomalies in the domains of perception, cognition
and attention, body and movement awareness, as
well as alarming alterations in the domain of selfawareness, anomalies which usually predated the
onset of psychotic symptoms. In the continental
Europe, an Austrian psychiatrist, Joseph Berze,
collected rich clinical data demonstrating a variety
of subjective experiential anomalies occurring prior
to, and at the onset of schizophrenia, which he
grouped into the categories nearly isomorphic with
those of McGhie and Chapman (23). Gerd Huber,
Gisela Gross, Joachim Klosterkotter and their
colleagues in Germany pursued this research line
for several decades. In a series of long-term
investigations of schizophrenic patients, they studied qualitative experiential anomalies of the type
already addressed by Berze and McGhie. They
confirmed a status of these experiences as important phenotypes of schizophrenia which usually
were present already in the preonset stages of the
disease. They coined these symptoms as the !basic
symptoms", on a hypothetical assumption that
these features were non-psychotic antecedents of
full-blown psychosis and therefore causally proximate to the underlying biological dysfunctions
(24, 25). These symptoms are defined in the Bonn
Scale for the Assessment of Basic Symptoms
(BSABS) (26), a comprehensive interview schedule
translated into several languages, including Danish,
and available in a preliminary English version from
its authors (27).

Aims of the study

The purpose of the present study was to assess

specificity of certain experiential anomalies, as
measured by the BSABS, by comparing their
lifetime frequencies among the patients suffering
from residual schizophrenia and from psychotic
bipolar disorder in remission.
Material and methods
Patients

All patients were recruited from the psychiatric

out-patient or day-patient facilities of the Corporation of Copenhagen University Hospitals, and
were required to suffer either from residual schizophrenia or a psychotic bipolar disorder in
remission, according to the DSM-IV diagnostic
criteria (28). The referring clinicians were unaware
of the exact study purpose. The diagnoses assigned
by the treating clinical psychiatrists were verified
with respect to the operational criteria by a
consensus rating of two senior research psychiatrists using the OPCRIT symptom checklist (27).
The BSABS interview

The Danish BSABS version (26) was only published in 1995, after a laborious translation process
with a very close participation of its authors, and
involving backward translations to both German
and English. Selected BSABS items, especially on
perceptual and cognitive disorders (CDs) were
included in several of our schizophrenia studies
prior to 1995.
The BSABS is a semi-structured interview consisting of 98 principal items, most often divided
into further subcategories, and described in a
prototypical manner, i.e. briefly defined and illustrated by examples of typical self-descriptions,
supplemented by differential-diagnostic guidelines,
question examples and suggestions of probes. The
interview is divided into sections comprising
!dynamic deficiencies" (e.g. anergia, anhedonia),
anomalies of cognitive-perceptual and motor
experience, cenesthesias (CEN) (abnormal bodily
experiences), and auto-protective efforts. Each item
is scored as absent, doubtfully present or definitely
present. The time span covered by the interview
may vary with the study purpose.
In the present study, the patients were inquired
about the anomalies of experience on a lifetime
basis, i.e. the interview also focused on the experiences outside the symptomatic episodes. The average interview duration was approximately 23 h.
127

Parnas et al.
All interviews were conducted by one of us (PH), a
senior psychiatrist with extensive research interview experience from a genetic linkage study, and
a principal translator of the BSABS into Danish,
and formally trained in Germany in its use by
Dr Klosterkotter, a co-author of the BSABS. The
interviewer was blind to the DSM-IV diagnostic
status of the patient, but, naturally, he could not
always remain so during the course of the interview. The reliability of the BSABS is high (27) but
its application requires both expert clinical experience and extensive training. The kappa reliability
coefficients for single scale items used in the present
study were all above 0.60 (mean 0.72) between
the interviewer (PH) and a consensus rating by two
other clinicians (JP and LJ).
Data condensation and data analyses

The data were condensed into scales using a

rational clinical approach, motivated by our previous research experience (3134) and our theoretical phenomenological orientation (35, 36). The
interview items were grouped into seven a priori
scales (Table 1). Each scale was subjected to an
item analysis, which attempted to maximize coefficient alpha (37) by emphasizing biserial correlations between items and scale totals. This method
is related to other approaches to aggregating items
into scales, e.g. factor analysis but generally yields
superior results (38). Only one item from the total
original item pool was removed because of alpha
degrading tendency. The intention behind the
composition of the individual scales was to capture
essential dimensions of the schizophrenia-spectrum
pathology (35, 3941), i.e. 1) a general decline
in the affective potential, 2) a subjectively experienced unease in the interpersonal/social contexts,
3) !perplexity (PY)", i.e. a disturbed prereflective
articulation or grip of meaning, 4) experience of
alterations in the processes of cognition, 5) anomalies of self-awareness, 6) anomalous awareness of
the body, and 7) perceptual distortions.
The interview items were originally coded as 0
(not present), 1 (doubtfully present) and 2 (definitely present); yet for the majority the patients only
scores 0 or 2 were actually given. Hence the score
of 1 was recoded into 0 (not present) and 2
redefined as 1 (present) for all items. Two statistical
analytic approaches were employed. First, conventional MannWhitney tests (the scales can be
considered as being ordinal) were performed,
with diagnosis as the independent variable and
the scale scores as the dependent variables. Secondly, in order to obtain a clinically more useful
picture of the discriminatory power of the scales,
128

Table 1. A priori scales with Cronbach's as and the BSABS-item numbers

Diminished affectivity (DA; a 0.69)
Diminished initiative and dynamism (A4)
Anhedonia (A 6.1)
Diminished feelings for others (A 6.3)
Diminished need for interpersonal relations (A 6.4)
Disturbed contact (DC; a 0.61)
Lack of ability for interpersonal contact (A 7.1)
Vulnerability to interpersonal contact (B 1.3.1)
Inability to tolerate crowd (B 1.3.2)
Increased impressionability by others" behaviour (B 2.2)
Increased impressionability by others" suffering (B 2.3)
Perplexity (PY; a 0.66)
Ambivalence (A 5)
Inability to discriminate between own feelings (A 6.2)
Hyperreflexivity/loss of naturaleness (B 3.1)
Disturbed receptive language (C 1.6)
Inability to re-visualize (C 1.14)
Inability to understand symbols (C 1.16)
Inability to grasp significance of perception (C 2.7)
Heightened perception (C 2.8)
Captivation of attention by perceptual detail (C 2.9)
Derealization: strangeness (C 2.11.1)
Derealization: intrusive perception (C 2.11.2)
Cognitive disorder (CD; a 0.63)
Thought interference (C 1.1)
Thought pressure (C 1.3)
Thought block (C 1.4.1)
Successive thought block and thought interference (C 1.4.4)
Disorder of expressive language (C 1.7)
Diminished thought initiative and goal-directedness of thinking (C 1.13)
Self-disorder (SD; a 0.65)
Psychic depersonalization (B 3.4)
Somatic depersonalization (D 1.1)
!Mirror" phenomenon, e.g. impression of a change in one's mirror image
(C 2.3.6)
Experience of discontinuity in own action (C 2.10)
Cenesthesias (CEN; a 0.55)
Electrical bodily sensations (D 5)
Sensation of movement, pressure or pulling in the body or on the
body surface (D 7)
Sensations of lightness, heaviness, levitation, falling (D 8)
Sensations of constriction, dilatation, shrinking or expansion of the body (D 9)
Perceptual disorder (PD; a 0.63 )
Unclear seeing (C 2.1.1)
Partial sight (C 2.1.3)
Photopsia (C 2.2)
Micro-macropsia (C 2.3.2)
Meto-chromopsia (C 2.3.4)
Changes in perception of others" faces or figures (C 2.3.5)
Skewed sight/disturbed perspective (C 2.3.8)
Disturbed sense of distance (C 2.3.9)
Disturbed rectilinearity (C 2.3.10)
Dysmegalopsia (C 2.3.11)
Abnormal persistence of visual irritation (C 2.3.12)
Akoasm (hearing unformed noise, e.g. tinnitus) (C 2.4.2)
Changed intensity or quality of sound (C 2.5.1)

a series of logistic regressions with odds ratio

calculations were conducted, with scale scores as
independent variables and the diagnostic status as
the dependent variable. The scale scores were
here dichotomized into comparably sized groups.
The dichotomization of the scales allowed for a

Experience in schizophrenics and bipolars

Table 2. Sample description
Number
of patients (males)

Age, mean
(SD)

Duration
of illness, years (SD)

Medication-life-time:
antipsychotics

Medication-life-time:
lithium

Medication-life-time:
antidepressants

21 (11)
23 (14)

33.9 (8.2)
45.5 (9.9)

9.4 (7.6)
15.1 (8.7)

21
22

3
19

7
21

Schizophrenia
Bipolar illness

calculation of P-values using the Fishers exact

test, which is desirable when the sample size is too
small to rely on the asymptotic tests. Eight models
were analyzed: seven univariate models, with each
scale entering into the model one at a time, and one
multivariate model testing all seven scales simultaneously because the scales were intercorrelated:
Pearsons mean r 0.37, range 0.100.59. Furthermore, 21 models, in which the scales were
entered two at a time, were analyzed, in order to
examine potential interactions between the scales.
Two-tailed P-values < 0.05 were considered to be
statistically significant.
Results

The patients were all in the advanced illness stages

(Table 2). There were no sex differences between
the groups, but the bipolar group was significantly

older than the schizophrenia sample (P < 0.01).

No correlation was observed, however, between
the age and the scale scores within the diagnostic
groups or between the scale scores and the illness
duration. In the univariate with MannWhitney
comparisons of the scale scores as dependent
variables, schizophrenics and bipolars scored
equally on diminished affectivity (DA). On all the
other scales the schizophrenia group tended to
exhibit higher scores, and significantly so on four
of them (Table 3): PY, CD, self-disorder (SD), and
perceptual disorder (PD).
The results of logistic regressions, with dichotomized scale scores as independent variables and
diagnostic status as the dependent variable appear
in Table 4. In the univariate comparisons, schizophrenic diagnosis was predicted by high scores on
PY, SD, and PD. Table 4 also shows the results of
a multivariate regression model, in which all scales

Table 3. Scale scores as a function of diagnosis

Scale

Bipolar
mean (SD)

1
2
3
4
5
6
7

2.75
1.55
1.74
1.00
0.55
0.39
0.63

Diminished affectivity (DA)

Disturbed contact (DC)
Perplexity (PY)
Cognitive disorder (CD)
Self-disorder (SD)
Coenesthesias (CEN)
Perceptual disorder (PD)

Schizophrenia
mean (SD)

(1.31)
(1.49)
(1.05)
(1.13)
(0.94)
(0.56)
(0.79)

2.65
2.42
3.36
2.01
1.47
1.03
1.91

P-values from
MannWhitney U-test

(1.28)
(1.43)
(2.35)
(1.44)
(1.17)
(1.16)
(1.87)

0.855
0.051
0.021
0.026
0.002
0.069
0.007

Table 4. Logistic regression analysis with status of schizophrenia as outcome and DA, DC, PY, CD, SD, CEN and PD as covariates

Covariate
Diminished affectivity (DA) (four items)
Disturbed contact (DC) (13 items)
Perplexity (PY) (11 items)
Cognitive disorder (CD) (six items)
Self-disorder (SD) (four items)
Cenesthesias (CEN) (four items)
Perceptual disorder (PD) (13 items)

Score
groups

N. Sch.

N. Bip.

Percentage
in score group

[0;3[
[3;4]
[0;2[
[2;5]
[0;2]
]2;8]
[0;1]
]1;5]
[0;1[
[1;4]
[0]
]0;3]
[0;1]
]1;7]

7
14
7
14
9
12
9
12
5
16
9
12
9
12

10
13
14
9
17
6
14
9
17
6
14
9
18
5

38.6
61.4
47.7
52.3
40.9
59.1
52.3
47.7
50.0
50.0
52.3
47.7
61.6
38.6

Odds Ratio
(95%-CI) univariate
1.00
1.54
1.00
3.11
1.00
3.78
1.00
2.07
1.00
9.07
1.00
2.07
1.00
4.80

(reference)
(0.455.24)
(reference)
(0.91-10.69)
(reference)
(1.0613.45)
(reference)
(0.626.91)
(reference)
(2.3135.65)
(reference)
(0.626.91)
(reference)
(1.2917.88)

Fisher's exact
P-value univariate
0.489
0.066
0.035
0.231
0.0007
0.231
0.015

Odds Ratio
(95%-CI) multivariate
1.00
1.07
1.00
1.59
1.00
2.05
1.00
0.78
1.00
5.61
1.00
0.84
1.00
3.02

(reference)
(0.235.02)
(reference)
(0.31-8.21)
(reference)
(0.3213.36)
(reference)
(0.134.75)
(reference)
(1.2126.05)
(reference)
(0.135.64)
(reference)
(0.4819.17)

Type III P-value

multivariate
0.931
0.580
0.449
0.787
0.024
0.856
0.237

Univariate: with only one scale at a time. Multivariate: adjusted for all seven scales" variables at a time. Bold values are in significant Odds Ratios and corresponding P-values.

129

Parnas et al.
were tested simultaneously. Only elevated score on
SD was here predictive of schizophrenia diagnosis.
A similar result emerged when only the scales
significantly differentiating in the univariate comparisons (PY, SD, and PD) were entered into the
multivariate equation. None of the 21 interactions
tested between two scales at a time reached the
probability level of 0.001, which was set as statistically significant because of the high number of
tests.
Discussion

This study demonstrates that schizophrenia, when

compared with bipolar psychosis, is associated
with increased levels of qualitatively anomalous
subjective experience, especially in the domain of
self-awareness, articulation of prereflective meaning, and perceptual experience. Other scales were
either entirely non-discriminating (sense of DA or
CEN) or discriminated only at a nearly significant
level (disturbed interpersonal contact). All patients
were in a stable, remitted condition, minimizing
potential effect of concurrent psychosis on the lifetime measurements of experiential pathology.
However, in view of the well-documented
memory deficits in schizophrenia, a possibility of
differential recall between the diagnostic groups
might have operated so as to attenuate the
between-group differences.
Recent literature is replete with the studies using
self-rating questionnaires and reporting non-specific feelings of distress, e.g. lack of concentration,
apathy, nervousness, irritability in various samples
of schizophrenia patients (4250). The scales used
in these studies do not target the qualitative or
structural alterations of subjective experience of
the type examined here, and originally described by
Berze, McGhie, Chapman and Huber, perhaps
with the exception of certain scales assessing
schizotypal dimensions (51) and the Frankfurt
Complaint Questionnaire (52, 53), which measures
phenomena similar to those described in the
BSABS. However, it is questionable, both on
methodological and empirical grounds, whether
self-rating instruments are ideally suited for assessing subtle changes in the qualitative structure of
subjective experience (36, 5456).
To the best of our knowledge, there are only
four studies that are methodologically comparable
with the present study. Ebel et al. (57) employed
the BSABS in a comparison of 30 patients with
remitted schizophrenia with 30 remitted melancholic patients. The schizophrenia group exhibited
more qualitative experiential anomalies in the
processes of perception and cognition. Cutting
130

and Dune (58) administered a self-developed

interview schedule to 20 remitted schizophrenia
patients and 20 remitted depressed patients, and
found that schizophrenia was associated with
qualitative anomalies of visual-perceptual experiences and, to a lesser extent, with qualitatively
altered cognitive experiences. They concluded that
the processes of experience undergo a !quantitative
decline in intensity or efficiency" in affective
patients and a !qualitative alteration" in schizophrenia (p. 228). Interestingly, the authors
observed that the patients" accounts of anomalous
experience were remarkably consistent across
occasions and interviewers. Klosterkotter et al.
(59, 60) administered a shortened version of the
BSABS to two samples of diagnostically heterogeneous patients (n 489 and 243) and controls: in
all comparisons, the schizophrenia group scored
higher on each of the BSABS subscales than
substance-induced, neurotic and personality disorders and normal controls. In addition, schizophrenic patients scored higher than depressed patients
on the scales targeting cognitive-PDs and CEN.
Our study extends the findings quoted above,
suggesting that certain qualitative experiential
alterations are not simply markers of psychosis in
general, but aggregate selectively in schizophrenia.
We have reported elsewhere that the BSABSdefined anomalous cognitive and perceptual
experiences also occur in schizotypal individuals
identified in a genetic family study (61).
The issue of prodromal specificity of the BSABSdefined anomalies of subjective experience was
recently addressed by Klosterkotter et al. (27) in a
prospective 10-year follow-up study of non-psychotic psychiatric patients. The initial presence of
the cognitive-perceptual basic symptoms was
highly predictive of a subsequent development of
schizophrenia, correctly predicting the outcome in
78% of the sample (27) (Table 5).
The joint evidence from this and the methodologically similar studies quoted above, indicates
that schizophrenia is differentially associated with
qualitative aberrations in several modalities of
conscious experience, aberrations that may turn
out as useful for early differential diagnosis and
hence assist in the prediction of future schizophrenia among non-psychotic psychiatric patients.
Of particular interest here is our finding of the
discriminating value of the anomalies in selfawareness [albeit it must be pointed out that the
BSABS measures are rather crude with respect to
the potential range of manifestations of SDs
(32, 38)]. In two retrospective phenomenologically
guided studies of first-onset schizophrenia spectrum patients (n 20 and 19, respectively),

Experience in schizophrenics and bipolars

qualitative alterations in self-awareness were found
to be the dominating experiential aspect of the
preonset phases (62, 63). We have replicated this
finding quite recently on a larger sample (n 155)
of diagnostically mixed first admitted patients: disorders of self-experience discriminated very strongly
between the schizophrenia spectrum patients and
the patients with various non-spectrum diagnoses
(35). Thus, alterations of the sense of self may
perhaps point to a core phenomenological feature
of schizophrenia, with important implications
for diagnostic boundaries and pathogenesis
(8, 41, 64, 66).
In conclusion, certain qualitative alterations of
subjective experience seem to antedate the emergence of psychotic symptoms in schizophrenia and
it appears that this evolution may follow characteristic, i.e. non-random, phenomenal patterns
(25, 64, 66).
The disorders of subjective experience have been
proposed, mainly on the basis of their factorial
structure, to constitute an independent symptom
dimension in schizophrenia (45). However, factorial structures are notoriously sensitive to the
samples from which they derive and their illness
stages (67) and are moreover strongly influenced by
the composition of the items and the instruments
used in the first place to elicit these items {the socalled methodological factors [see (68) for a recent
assessment of factor analysis in psychometric
research]}. It is therefore likely that observed
behaviours and expressive features on one hand
third-person data, and the information obtained
from subjective reports on the other hand firstperson data, may mathematically gravitate into
separate dimensions, without implying a real split
between experience and expression or a homogeneity of subjective experience.
Acknowledgments
This study was supported by a grant from University of
Copenhagen (Dr Handest), a grant from the Corporation of
Copenhagen University Hospitals (Dr Parnas) and a grant
from the Danish National Research Foundation (Dr Parnas).

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