Suicidality Tied to ‘Self-Disorders’ in Early Schizophrenia

Among patients having their first episode of schizophrenia, suicidality is clearly associated with an altered sense of self, or what some experts have termed “self-disorders,” a study of 49 adult patients shows.

Self-disorders are anomalous subjective experiences, described as “subtle disturbances of the person’s spontaneous experience of himself or herself as a vital subject naturally immersed in the world. As nonpsychotic distortions of self-awareness, they antedate the development of clearly delusional experiences and are highly prevalent in the prodromal and early psychotic phases” of schizophrenia, said Dr. Elisabeth Haug of the division of mental health, Innlandet Hospital Trust, Ottestad, Norway, and her associates.

The investigators assessed the relationship between self-disorders and suicidality in patients newly diagnosed as having schizophrenia spectrum disorder, because suicide risk is particularly high at this stage of the disease. They used data from the Norwegian Thematically Organized Psychosis study, which collected information from all mental health treatment facilities covering two counties with a pooled population of 375,000 people.

The study sample of 49 adults had been diagnosed over a 2-year period as having schizophrenia (38 patients), schizoaffective disorder (9 patients), or schizophreniform disorder (2 patients).

All the study subjects were assessed using the Examination of Anomalous Self Experience (EASE) manual, a 57-item questionnaire that addresses five domains of self-disorders: cognition and stream-of-consciousness, self-awareness and presence, bodily experiences, demarcation/transitivism, and existential reorientation. It includes questions such as “Have you ever felt as if thoughts in your head are not really belonging to you?” and solicits descriptions or examples from the patient rather than simple yes-or-no responses.

Each EASE interview took 30-90 minutes.

The investigators found that patients with newly diagnosed schizophrenia spectrum disorder also had high levels of suicidality and self-disorders (P = .036) and high levels of depression (P less than .001). “Our main finding is that of a clear association between current suicidality and [self-disorders], which appears to be mediated by depression,” Dr. Haug and her colleagues said (Compr. Psychiatry 2012;53:456-60).

This result “strongly support[s] the role of self-disorders in the development of suicidal ideation and behavior in this patient group.”

In a previous study, other researchers postulated that patients with self-disorders experience specific feelings of inferiority and solitude, which differ from “normal” feelings of low self-esteem or loneliness and represent “more fundamental feelings of being profoundly dissimilar to other people and thus unable to relate to others,” Dr. Haug and her associates noted.

If self-disorders play a key role in the development of depression in early schizophrenia, it follows that they “could be a rational clinical target for the prevention of suicidality,” they added.

The investigators noted: “Our cross-sectional design makes it difficult to rule out the possibility that depressed patients develop and report more [self-disorders]. Previous studies of the temporal relationship between these factors, however, indicate that the subjective experience of psychologic deficits in patients with schizophrenia prone to depression is high even when they are not depressed.”

This study was supported by Innlandet Hospital Trust, South-East Health Authority, Eastern Norway Health Authority, and a European Union Marie Curie Fellowship. No financial conflicts of interest were reported.

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