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6. Ego disorders in psychosis – transcultural or modern
Western correlate of self experience?
The question whether prerefl ective self- awareness can be
conceptualized as a universal human trait and whether it can be
altered in psychotic disorders is highly relevant for transcultural
psychiatry and the diagnosis of psychotic disorders. So- called
fi rst rank symptoms of schizophrenia (Schneider 1942) include
“Ego disorders”, e.g. passivity phenomena such as thought
insertion or alien thought control and experiences such as
telepathy, i.e. the feeling that other persons can read one’s own
thoughts. As such, they are characteristic, so- called “fi rst rank”
symptoms of schizophrenia [54]. They describe a disturbance
in a person’s awareness or knowledge of one’s thoughts or, as
Karl Jaspers would put it: a procedural knowledge about our
own thinking, to which – in contrast to the experience of outer
objects – we have a privileged access [29]. Ego disorders are
therefore distinguished from paranoid ideation, which concerns
a misrepresentation of the meaning or implications of outer
objects or processes to which patients and psychiatrists have
equal access. The situation is different when a patient describes
what is called “ego disorders”: it makes no sense to discuss with
a person who describes that his thoughts are manipulated in
his mind whether this experience is wrong – only the patient
has a direct awareness of his own thoughts. It has been argued
that one’s own thoughts are more closely connected with
self- consciousness than the experience of one’s own body. For
example, I may misidentify my own arm in case it is anesthetized
and I fi nd myself – after an accident – within a heap of human
beings, while this misidentifi cation is not possible with respect
to my own thoughts [14].
However, this argument may be wrong: in the example just
reported, the anaesthesia of the arm is required for me to be
able to misidentify it – however, this is a pathological condition
which results from nerve dysfunction caused by the accident. In
such a pathological circumstance, I may misidentify my own arm
– just as I misidentify my own thought as alien or inserted by
somebody else in the pathological state of psychosis. Therefore,
direct access may exist both to one’s own thoughts as to the
representation of one’s own body, and as e.g. suggested by
Metzinger, the phenomenal self- model may be maintained by
continuous input of sensory and sensitive information from the
body [42]. Likewise, Schneider counted passivity phenomena
concerning one’s own body parts (namely that they are e.g. under
alien control) among his “fi rst rank symptoms” of schizophrenia
– on an equal level with symptoms regarding alien thought control
[54]. However, the claim that “my” thoughts are not really
“my own” but instead “inserted” or “controlled” by someone
else remains paradoxical in a way that “alien” control of visible
objects (including visible body parts) is not: because how do I
know that I suffer from inserted thoughts if they do not remain
accessible and hence to some degree are still “my” thoughts?
To explain apparently paradoxical experiences such as
thought insertion in psychosis, several models have been
developed that distinguish a sense of “agency”, “control” or
“authorship” with respect to one’s own thoughts from “ownership”
[17, 18]. However, to date the topic remains controversial.
Moreover, can such symptoms be found in all cultures during
the manifestation of schizophrenic psychosis and do they thus
A. Heinz et al. / European Psychiatry 27 (2012) / supplement n°2 / S32-S43 S37
represent a common human quality of self- experience or does
culture infl uence the way of attributing control over one’s own
thoughts or body? A study of the WHO suggested that fi rst rank
symptoms can be found in all (examined) cultures independent
of the degree of industrialisation, and that schizophrenic psychosis
appear with comparable frequency in different cultures,
specifi cally when schizophrenia is diagnosed using Schneider’s
traditional concept of fi rst rank symptoms [50]. On the other
hand, ethnologists like Fortes and Mayer (1969) suggested that
schizophrenic psychosis was not found in a traditional setting
in Ghana but appeared once young men entered large cities
as migrant workers [13]. Also, the German psychiatrist Wulff
described that in the 1960s in Vietnam, he could not fi nd ego
disorders in schizophrenic psychosis [24]. He explained this
fi nding with the structure of the local language: a speaker in
Vietnam would not refer to himself as “I” but instead name his
social status, for example, he would address himself as a father,
older brother etc. An abstract, common denomination for any
actor would only be found in love poems, in which the speaker
wants to express his deepest despair, namely being reduced to
the universal characteristic of any personal existence – to be a
“slave of the king”, a state shared by all Vietnamese regardless
of their social status [24]. It could be argued that such linguistic
peculiarities only concern different ways of expressing (fundamentally
similar) individual experiences; however, some
authors such as Müller (1981) referred to Whorf’s linguistic
studies and suggested that linguistic structures indeed interact
with personal experiences [44]. For example, among Native
Americans such as the Sioux, experiences are often expressed
in the passive voice, which refl ects a feeling of being affected by
environmental constellations rather than being a determined
actor within these circumstances. Also in Homers “Ilias” and
“Odyssey”, it is not the individual person but rather the Olympic
gods that stir up the anger in a subject or calm him down in
time to avoid an active fi ght. The actions of the heroes of these
stories can thus rather be attributed to such divine forces and
not to individual intentions. Of course one can ask whether
these are just poetic expressions of human experiences, which
otherwise do not differ from our modern experience of the self.
However, several fi ndings suggest that our current Western way
of experiencing and conceptualising our self is based on historically
unique experiences and that concepts of mental disorders
such as schizophrenia, which is characterized by ego disorders,
require elaborate and widely accepted concepts of the self and
of self- control. Only if a majority of subjects observe their own
behaviour and agree that they are indeed in active control of their
own thoughts and that the “I think” can accompany any of their
mental representations, can the loss of such an ability be used
as a pathological symptom that indicates “ego disorder” [52].
Indeed, the fi rst description of schizophrenic psychosis in modern
times can be found in England at the end of the 18th century,
when a patient described how his thoughts were controlled by
machines [39]. The hypothesis that cultural factors infl uence the
way we observe ourselves and the signs and symptoms we use
to diagnose a disorder is supported by the above quoted study of
Fortes and Mayer (1969), who observed that among the Tallensi
of Northern Ghana, schizophrenic psychoses were only described
when the young men left their traditional surroundings and
worked as migrants in the new colonial cities [13].
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