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I have written this article from my personal experiences of schizophrenia as fundamentally a self-disturbance and not simply a biochemical imbalance. In the article, I attempt to use a theory of “existential permeability” to explain the various symptoms of the condition and how psychiatrists could help in recognizing the patient's self-disturbance.
If you ask a psychiatrist about the role of the patient's self in schizophrenia, you will probably get a very confused look. At least this is my experience. After all, to many psychiatrists, schizophrenia is a disorder of thought and perception that has a strong biochemical basis. Symptoms are classified and categorized into positive, negative, and cognitive aspects, and although each individual sufferer might have a different clinical profile, the clinician's response remains pretty much the same: to prescribe antipsychotic medications. Indeed, medications can and do help with many of the frightening and distressing symptoms of schizophrenia, but they do not resolve anything beyond the apparent manifestation itself. What lies behind the symptoms is a tormented self, a highly personal experience unchangeable and irreplaceable by any physical treatment. Since I was diagnosed with schizophrenia last year, after 2 unfortunate misdiagnoses, my symptoms exacerbated each time I got hospitalized. Despite the “usual” voices, alien thoughts and paranoia, what scared me the most was a sense that I had lost myself, a constant feeling that my self no longer belonged to me. What made such an existential orientation even more intolerable is the voices incessantly telling me that the only way to reunite with my real self is to commit suicide. So I tried. Still, nothing had happened. I was simply sectioned again, detached from my real self, observing what was being done to me in a third-person perspective. When I said this to my psychiatrist after being rescued from the top of a multistorey car park, he dismissed my comment by saying that “you certainly communicate your distress clearly.” It was not even my own distress—I was totally separated from myself, not knowing what action I was taking, let alone considering how to “communicate” to others. I was unaware of myself, and my psychiatrist was unaware of me. What he chose to see was nothing but the symptoms alone.
Even though I am now stabilized on a new medication, I still cannot accept the diagnosis. The medication helps the observing self dominate over the suffering self, but the real ‘me’ is not here any more. I am disconnected, disintegrated, diminished. Everything I experience is through a dense fog, created by my own mind, yet it also resides outside my mind. I feel that my real self has left me, seeping through the fog toward a separate reality, which engulfs and dissolves this self. This has nothing to do with the suspicious thoughts or voices; it is purely a distorted state of being. The clinical symptoms come and go, but this nothingness of the self is permanently there. Not a single drug or therapy has ever helped with such nothingness. By nothingness, I mean a sense of emptiness, a painful void of existence that only I can feel. My thoughts, my emotions, and my actions, none of them belong to me any more. This omnipotent and omnipresent emptiness has taken control of everything. I am an automaton, but nothing is working inside me. Schizophrenia has silenced my real self, and even the observing self is biased by the process of subjective observation. In my opinion, schizophrenia is ultimately a disorder of the self, a disturbance of one's subjective self-experience and the external or objective reality. Curiously, instead of psychiatrists, many philosophical researchers have argued that schizophrenic symptoms are an inevitable and essential component of human experience that can have great personal and social significance. Their proposals include that schizophrenia can cause a form of exaggerated self-consciousness and a diminished sense of existence in the world.1,2
My view is that the key to understanding such self-disturbances lies within how one relates to the external world and how one attributes this relationship to interpreting oneself. For example, if a person relates too much to the outside world, to such an extent that he ignores his own internal self, this may result in him feeling being engulfed by others. On the other hand, if one finds little or no connection to the world, he may think that his self is going to implode and destroy him from the inside. Basically, I call this relationship existential permeability. This permeability between self and world has the potential to selectively open doors to multiple realities created and perceived by the individual, but every reality requires a solid sense of self. In order to consciously choose which reality is the best suitable, the person must first confirm that he exists in that reality. External reality is received as subjective to the perceiving individual, and the process of thought and perception modifies and distorts objective reality to one's own liking. Behind all this is a powerful self-consciousness, resilient to disorganization and destruction. In schizophrenia, the existential permeability is so disordered that the individual fails to filter through all the realities that he confronts, thus being overwhelmed by them. All the incoming information from these realities can easily debilitate the individual's sense of self and his connection to the world. For example, my sense of self is totally crushed when the “bubble” surrounding my self-consciousness is destroyed by this unstable permeability. Multiple realities permeate and penetrate through me, bringing more and more confusion and instability, until the entire self-experience disintegrates. The severity of self-disturbance depends on such permeability, and a disrupted permeability can cause at least 3 different types of disturbed self-experience within the schizophrenic spectrum, primarily associated with positive symptoms: the dissolved, the disorientated, and the disembodied self. They can occur together or separately during different phases of the illness.
Firstly, the dissolved self involves an excessive amount of permeability between the individual and others, causing an effect similar to that seen in severe depression. The self is no longer an entity, but a solution made of millions of invisible particles. The individual might feel that he is nonexistent, flat, or emotionally empty. I consider the Cotard delusion, in which the sufferer finds himself “dead,” as one example of the dissolved self. My experience of the dissolved self includes hearing voices that tell me that “you are not real,” “you don't exist,” and even “you are already dead.” It is curious how something that is only experienced as subjectively “real” can have such an impact on one's existential orientation. Hearing voices, in my opinion, however, is also a manifestation of the disembodied self, which I will describe in later sections.
In the disorientated self-experience, the self still exists, but the individual is troubled by an unstable existential permeability, unsure of how to relate to the world. Sometimes, this can manifest itself in the forms of paranoid ideations in which the person finds others hostile against him but is helpless toward such hostility. It is also dissolution of ego boundaries (the selectively “permeable membrane” between self and world and between one's mentality and reality): A series of thought disorders can fall into this category, such as thought echo, broadcast, and withdrawal where what is originated from the self and what is not are confused, although the person is aware that the thoughts still belong to them.
Lastly, the disembodied self represents perhaps the most troubling aspect of self-disturbance in schizophrenia, where the existential permeability is constantly shut down. The person cannot be comfortably related to the world or to his inner self. In this case, the self is separated from normal mental activities, a process similar to dissociation but the individual does not know he has been separated (hence the reality testing is no longer intact) from himself. This is linked to a disrupted ego boundary as well, but instead of dissolution, the disembodied self experiences a total alienation. Actions, emotions, and thoughts become strange to the individual, so he attributes them to an external agency, a third-party who controls everything he experiences. One piece of obvious supporting evidence is “made” happenings or passivity phenomena in technical terms. Auditory verbal hallucinations, or “hearing voices,” are a more extreme presentation of the disembodied part of the self, where unconscious internal speech is cut off from the rest of mental activities. Some other aspects of thought disorder, including thought insertion, are also examples of such disembodiment in which the individual's own thoughts are not felt as being created by his mind but are put into him from the outside. In fact, all 3 types of disturbances in existential permeability are rooted in a silenced and diminished sense of self-consciousness, a disappearing awareness that is not part and parcel of one's ego any more. So, what about negative symptoms? Can this theory of existential permeability explain anything such as a lack of goal-directed behavior, affective flattening, and poverty of speech? Personally, I think the answer is yes but from a slightly different angle. If one is unable to enjoy a consistent and continuous sense of self, it is naturally difficult for him to express his inner turmoil. When the very elementary basis of self-experience is disrupted, communicating to, and participating with, others will automatically seem secondary, even insignificant. What is the purpose of volition when one is no longer himself? When nothing is real, even one's own self, how can anybody expect him to show a normal range of feelings toward others? The role of existential permeability in negative symptoms is that a partially blocked permeability allows the person to perceive reality as normal and present but deprives them of the ability to express their own responses toward the outside world.
Schizophrenia has given the suffering individual an unwanted new reality, from which it is hard to escape. I only wish the psychiatrists would recognize this painful reality and rescue the sufferer from his isolation by helping him reconstruct and protect his existential permeability, both to his real self and to the world. It should not be a complaint from the sufferer in order to “communicate one's distress clearly,” but for the psychiatrist to preemptively detect the self-disturbance, to awaken the silenced self.