bs_bs_banner

First Impact Factor released in June 2010

and now listed in MEDLINE!

Early Intervention in Psychiatry 2014; ••: ••–•• doi:10.1111/eip.12140

Original Article
Premorbid self-disorders and lifetime diagnosis in
the schizophrenia spectrum: a prospective
high-risk study
Josef Parnas,1,3 John Carter2 and Julie Nordgaard3

Abstract the time of premorbid assessment, we

1
Center for Subjectivity Research,
University of Copenhagen, Copenhagen,
3
Psychiatric Center Hvidovre, University of
Copenhagen, Hvidovre, Denmark, and
2
Horizon Consumer Science, Glendale,
California, USA
Corresponding author: Professor Josef
Parnas, Center for Subjectivity Research,
University of Copenhagen, Njalsgade 142,
2300 Copenhagen, Denmark.
Email: jpa@hum.ku.dk
Aim: The notion of a disordered self as
a core disturbance of schizophrenia
was proposed in many foundational
texts. Recent studies, spurred by
the development of the Examination
of Anomalous Self-Experience
(EASE), seem to indicate that self-
disorders are a specific manifesta-
tion of schizophrenia vulnerability.
Follow-up studies of help-seeking,
prodromal and first-admission
patients have demonstrated the
utility of self-disorders for predicting
later schizophrenia-spectrum dis-
turbance. We wished to extend these
findings by gauging the predictive
value of self-disorders in a premorbid,
non-clinical population at high risk
for schizophrenia.
Methods: Children from the Copen-
hagen High-Risk Project with high-
genetic risk for schizophrenia
(N = 212) were assessed premorbidly
(average age = 15), and diagnostically
re-evaluated after 10 and 25 years.
Since the EASE was not available at
hypothesized that a proxy scale drawn
from the Minnesota Multiphasic
Personality Inventory (MMPI) could
distinguish those who later developed
a schizophrenia-spectrum disorder
(N = 68) from those who remained
healthy (N = 64). The Self-Disorder
Scale comprised 32 items whose
content suggested an aspect of self-
disorder as measured by the EASE.
Results: Premorbid Self-Disorder
Scale scores significantly predicted
lifetime schizophrenia-spectrum
diagnosis in the high-risk cohort.
Although there was considerable item
overlap between the new scale and
an existing MMPI scale (psychoti-
cism), the overlap did not account for
the Self-Disorder Scale’s predictive
efficacy.
Conclusion: The results support the
notion of self-disorders as a core vul-
nerability feature in schizophrenia,
detectable premorbidly in those
developing later schizophrenia-
spectrum disorders.

Received 9 October 2013; accepted 28 Key words: EASE, high risk, MMPI, schizophrenia spectrum,
February 2014 self-disorder.

INTRODUCTION subsequent systematic empirical studies demon-

The notion of disordered self as the core trait-phen-
otypic disturbance of schizophrenia was proposed
in all foundational texts on schizophrenia (e.g. 1–8).
In contemporary psychiatry, the notion of basic dis-
orders of self-experience (self-disorders, SDs) in
schizophrenia has only recently been rediscovered in
two independent clinical, in-depth qualitative inves-
tigations of first-admission schizophrenia-spectrum
patients in Denmark9 and Norway.10 A series of
strated that SDs aggregate selectively in first-admis-
sion schizophrenia and schizotypal disorders11–13 but
not in bipolar psychosis.14,15 SDs are detectable in
populations at high-genetic risk for schizophrenia13
and are associated with prodromal symptoms among
help-seeking, non-psychotic adolescents.16 SDs
predict psychosis in clinically at-risk prodromal
populations17 as well as new cases of schizophrenia-
spectrum disorders in a follow up of non-spectrum
psychiatric patients 5 years after first admission.18

© 2014 The Authors. Early Intervention in Psychiatry published by Wiley Publishing Asia Pty Ltd. 1
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium,
provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
Premorbid self-disorders and diagnosis
SDs affect the ‘core’ or ‘minimal’ experiential
self,19–21 that is, a structure that must be in place in
order for the experience to be subjective, that is, to
be someone’s experience. The core self refers to a
first-personal articulation of experience, typically
called ‘mineness’, ‘myness’, ‘for-me-ness’ or ipseity
(ipse = self, itself ).22 It is a sense of ‘I-me-myself’
that implicitly (pre-reflectively) permeates our con-
sciousness across the flux of time, experiences and
changing experiential modalities. The minimal self
founds the very basic sense of identity, a condition
for our ordinary experience of being a self-present,
bodily, demarcated and persisting subject of experi-
ence and action.
This sense of basic selfhood, a fundamental struc-
ture of subjectivity (consciousness), appears to be
challenged, unstable and oscillating in the
schizophrenia-spectrum disorders, resulting in
sometimes alarming and often alienating experi-
ences, typically emerging already in childhood or
early adolescence.19 People with these disorders feel
ephemeral, lacking core identity, profoundly (yet
ineffably) different from others and alienated from
the social world. There is a diminished sense of
existing as a bodily subject, various distortions
of first-person perspective with a failing sense of
‘mineness’ of the field of awareness (e.g. ‘my
thoughts have no respect for me’, ‘it seems as if my
thoughts were not mine’), spatialization of the
experiential contents (e.g. thoughts being experi-
enced as located, extended thing-like entities) and a
deficient sense of privacy of the inner world. Simul-
taneously, there is a failing sense of immersion in
the shared world (‘loss of common sense’) and an
inadequate non-reflective (immediate) grasp of self-
evident meanings (e.g. ‘why is the grass green?’), as
well as a general hyperreflectivity (e.g. ‘I only live in
my head’, ‘I always observe myself’.) SDs, although
varying in intensity, appear to be a specific hallmark
of the vulnerability for schizophrenia, thus belong-
ing more to the trait than to the state domain of
spectrum psychopathology.
Following our initial qualitative study,9 a scale for a
systematic, qualitative and quantitative semi-
structured phenomenological exploration of SDs
was created (Examination of Anomalous Self-
Experience, EASE23). The EASE construction, which
involved senior interdisciplinary scholars from three
European countries, was based on clinical-empirical
data from extensive in-depth interviews with schizo-
phrenia patients, a review of classic and contem-
porary German, French and English language
literature, and conceptual input from the philosophy
of mind and phenomenology.24 The EASE possesses
good to excellent interrater reliability among trained
2 © 2014 The Authors. Early Intervention in Psychiatry published by Wiley Publishing Asia Pty Ltd
interviewers.17,25,26 It consists of 57 main items and
explores five overlapping domains of experience: (i)
stream of consciousness (experience of cognition
and emotion); (ii) sense of presence/basic identity;
(iii) bodily experience; (iv) sense of demarcation
(‘ego boundaries’); and (v) existential reorientation
(e.g. finding a new life meaning) and solipsistic
experiences. The EASE exhibits high internal con-
sistency (Cronbach’s alpha above 0.8011,14) and a
monofactorial structure.11,27
Although all studies seem to support the notion of
SDs as a spectrum-specific manifestation of vulner-
ability, and follow-up studies of help-seeking, pro-
dromal and first-admission patients have shown the
utility of SDs for predicting later spectrum disturb-
ance,17,18 there have been as yet no attempts to iden-
tify SDs and gauge their predictive value in a
premorbid, not-help-seeking population at high
risk for schizophrenia.
In the present study, we therefore turned to the
existing data from the Copenhagen High-Risk
Project (CHRP)28 in order to explore this issue. The
CHRP is the largest and longest running prospective
study of children at high-genetic risk for schizophre-
nia. At the time of the initial assessment, subjects
showed no clinical symptoms and were not seeking
help for mental/emotional problems. Although the
EASE instrument had not yet been developed at this
time, we thought that if we could craft a rough ana-
logue of the same content areas with existing assess-
ments, it may hold promise for predicting later
spectrum disorder. The most suitable of the avail-
able assessments is the Minnesota Multiphasic Per-
sonality Inventory (MMPI), which contains a variety
of statements bearing on the first-person experi-
ence of the respondent. Several existing MMPI
scales have been shown to aid the prediction of
schizophrenia-spectrum outcomes.28–30 Our inter-
est, however, was not in replicating these successes,
but in identifying an a priori set of MMPI items,
selected purely on the basis of their similarity to
EASE content domains, and examining the predic-
tive properties of this analogue self-disorder scale.
Our criterion would be to select any MMPI item
statement that, if spontaneously presented as a
complaint by the subject in an EASE interview,
would motivate the EASE interviewer to explore it
in-depth as a potential token of SD.
It is important to bear in mind that there are sig-
nificant differences between the EASE and the
MMPI. The EASE scale is mainly qualitative, requir-
ing a high resolution, in-depth semi-structured
expert interview, and the items (anomalous experi-
ences) are first stipulated in general definitions and
explicated through prototypical examples. On the
 J. Parnas et al.

other hand, the MMPI is a quantitative, superficial including MMPI profiles which might be considered
and self-rated report on certain aspects of experi- invalid in a clinical context – specifically records
ence that are presented to the subject in rather with elevated F (infrequency) scores among samples
vague, everyday statements. at high risk for psychosis. Therefore, only partici-
pants missing an MMPI assessment (N = 24) or
whose MMPI record contained more than 50%
METHODS Can’t Say responses (i.e. more than 152 out of 304
total items; N = 15) were excluded from the analy-
We elected to test the hypothesis that premorbid ses. The MMPI records of the remaining participants
MMPI items analogous to the EASE scale will predict (N = 272) had a mean of 17.8% and a median of
later schizophrenia-spectrum disorder with data 15.1% Can’t Say responses.
from the CHRP. In order to create an MMPI scale that would be
phenomenologically tied to signs of anomalous self-
experience, selection of items was performed by one
Participants
of us (JP) who (i) has worked extensively with
The CHRP selected 207 children of mothers with Danish prodromal and first-episode schizophrenic
schizophrenia and matched them with 104 children youth; (ii) was the principal developer of the EASE
of parents without mental illness. The children (177 interview; and (iii) is relatively unfamiliar with the
boys and 134 girls) ranged in age from 10 to 18 MMPI in general and its predictive efficacy in this
(mean age = 15.1) when they were first assessed in sample in particular. JP selected 56 items from the
1962–1964. Any children suffering from a clinically complete MMPI 566-item set for content, which
manifest mental disorder were excluded from the could suggest a disturbance of self-experience as
sample at the outset. The participants were followed listed in the EASE.
up approximately 5, 10 and 25 years after the initial From this initial a priori selection of items,
assessment.31 Upon a review of both the mother and another one of us (JC), with greater familiarity with
the father’s psychiatric hospital records in 1980, the MMPI and its predictive properties in this
and personal interviews with fathers conducted in sample, constructed the final scale. First, 24 items
1980–1983,32 5 of the 104 participants originally were discarded because they were not among the
assigned to the low-genetic risk condition were 304 MMPI items assessed in 1962–1964. Next, the
crossed over to the high-genetic risk condition due remaining 32 items were subjected to reliability
to having mothers and/or fathers who developed a (internal consistency) analyses. Because the statis-
schizophrenia-spectrum disorder after 1962–1964. tical program we used (the RELIABILITY command
We use these revised group assignments (212 high in the SPSS analysis package) does not allow for
risk and 99 low risk) in the following analyses (see 33 missing values, and due to the high number of
for a full rationale). missing (Can’t Say) values in the MMPI data, exclu-
sion of cases due to one or more missing items
would have resulted in only 36 cases left for the reli-
Procedure
ability analyses; therefore, we decided to substitute
The MMPI was administered in a modified, abbre- a value of 0.5 for all missing values. In effect, this
viated form during the initial 1962–1964 assess- scales a Can’t Say response halfway between False
ment. A total of 262 items were removed, resulting in (scored as 0) and True (scored as 1). We believe this
a 304-item short form; in addition, participants substitution is justifiable given the non-standard
sorted cards bearing these items into one of three MMPI administration. After substitution of missing
piles, True, False and Can’t Say, thus resulting in a values, reliability analyses were run iteratively, each
higher number of Can’t Say (missing) responses time discarding the item which would result in the
than standard paper-and-pencil versions. Details of highest Cronbach’s alpha if deleted, and stopping
this assessment are described elsewhere.28 We when no further improvement was possible (see
decided against applying the traditional criteria for Cannon et al.35 for use of a similar scale construc-
MMPI profile validity for several reasons: (i) the tion procedure). This procedure resulted in the
reduction in the item pool precludes calculation of deletion of five items from the scale with a corre-
the standard T-scores used to determine profile sponding increase of Cronbach’s alpha from 0.870
validity; (ii) the non-standard administration pro- to 0.879. However, upon review of these results, the
duced a large number of profiles with Can’t Say researchers felt that this increase in internal consist-
levels traditionally considered invalid; and (iii) prior ency did not represent a substantial improvement
reports28,34 have supported the research value of over the initial scale selection; thus, a decision was

© 2014 The Authors. Early Intervention in Psychiatry published by Wiley Publishing Asia Pty Ltd 3
Premorbid self-disorders and diagnosis
made to revert to the original set of 32 items. These
items are listed in Table 1, together with the content
areas of the EASE to which each item seemed
related. From this item list, the Self-Disorder Scale
(SDO) was calculated by adding all items scored in
the direction of pathology (all True in this case), 1
point for each item. Missing value substitution was
not performed for the scale calculation; instead, the
resulting raw score was prorated for the presence of
missing items, and cases missing 50% or more of the
scale items were assigned missing scale scores. This
procedure is a slightly more conservative version of
the procedure used to compensate for excessive
missing values in previous analyses of this28 and
similar samples.36,37
Participants were given diagnostic assessments at
both the 10- and 25-year follow ups; diagnoses from
these assessments were reviewed in 1989 by a team
of psychologists and psychiatrists and consensus
DSM-III-R (Diagnostic and Statistical Manual of
Mental Disorders, Third Edition, Revised) lifetime
diagnoses were assigned.31 Of the 212 high-risk par-
ticipants, 32 were diagnosed with schizophrenia, 51
were assigned another diagnosis within the broad
schizophrenia spectrum (non-affective psychoses,
cluster A personality disorders), 43 had non-
spectrum Axis I or II disorders, and 70 remained free
of mental disorder. Of the 99 low-risk participants, 1
developed schizophrenia, 6 were assigned another
schizophrenia-spectrum diagnosis, 33 had another
Axis I or II disorder, and 57 did not develop any
mental illness. The remaining participants in each
group (16 high risk and 2 low risk) were unavailable
at both follow ups and thus were not assigned a
lifetime diagnosis.
Analysis
The study hypotheses were tested using the high-
risk sample (N = 212) only, as our interest was not in
testing the main effect of genetic risk (which has
been amply addressed in other publications), but in
uncovering the potentially additive predictive
power of premorbid self-disturbance. Our analytical
plan was relatively straightforward. First, we would
check for possible gender and age effects on the
SDO scale, which might confound predictive analy-
ses. If no gender or age effects were found, then a
one-way analysis of variance (ANOVA) would be run
comparing the premorbid SDO scale scores of those
who went on to incur a lifetime diagnosis in the
schizophrenia spectrum (schizophrenia plus other
schizophrenia-spectrum disorders) with those who
were later diagnosed as no mental illness. If either
gender or age effects were found, then that variable
4 © 2014 The Authors. Early Intervention in Psychiatry published by Wiley Publishing Asia Pty Ltd
would be added as a covariate in a one-way analysis
of covariance (ANCOVA). ANOVA/ANCOVA results
would then be verified using logistic regression. We
next planned to assess whether the number of
missing values in participants’ MMPI records served
as a potential confound in the analysis.
We were also interested to identify possible corre-
lations between the SDO scale (developed from an a
priori content analysis) and existing MMPI scales
already associated with schizophrenia-spectrum
illness. For example, several scales (F, 4, 8, Wiggins’
PSY (psychoticism), and Rosen’s Pz) have already
been shown to identify those at risk of schizophre-
nia in high-risk samples.28,37,38
RESULTS
Descriptive statistics for gender and age are
reported in Table 2 for each diagnostic group. Analy-
sis of possible demographic confounds revealed no
significant gender effect for SDO, but a significant
negative correlation between SDO scale score
and age at administration (Pearson’s r = −0.202,
P = 0.006).
Because of this correlation, age was included as a
covariant in an ANCOVA (SPSS package, UNIANOVA
procedure) assessing the relationship between SDO
score and lifetime diagnosis. High-risk participants
with valid data for the SDO scale and lifetime diag-
noses of either schizophrenia spectrum (N = 68) or
no mental illness (N = 64) were included in the
analysis.
The overall model was significant (F = 6.50,
d.f. = 2, P = 0.002) as was the main effect for the SDO
scale (F = 5.73, d.f. = 1, P = 0.018). The means and
standard deviations of the SDO scores for each diag-
nostic group are reported in Table 2. Notably, the
SDO scale means are in the expected direction: the
mean premorbid SDO score for the schizophrenia-
spectrum group (8.47) is 2 points higher (more fea-
tures of SD) than that for the no mental illness group
(6.52). Because the adequacy of the ANCOVA analy-
ses relies on numerous parametric assumptions, we
repeated the analyses using logistic regression and
obtained essentially the same results: SDO score
was a significant predictor of spectrum diagnosis,
with a one-point increase in SDO score resulting in a
9% increase in the odds ratio for spectrum outcome.
We next investigated whether the extent of
missing MMPI data varied systematically with
either the independent or dependent variable or
was randomly distributed with respect to these vari-
ables. There were no significant differences in the
percentage of missing values by lifetime diagnostic
 J. Parnas et al.

TABLE 1. Items composing the SDO with their EASE scale derivations

SDO EASE scale

MMPI # Item description EASE #(s) Item content area(s)

33 I have had very peculiar and strange experiences. 1.0–4.5 (Any item)
40 Most any time I would rather sit and daydream 2.4, 2.6 Diminished presence, hyperreflectivity
than to do anything else.
41 I have had periods of days, weeks or months 2.16, 2.18 Diminished initiative, diminished vitality
when I couldn’t take care of things because
I couldn’t ‘get going’.
48 When I am with people I am bothered by 1.7.4, 1.10 Gedankenlautwerden as voices, inability to
hearing very queer things. discriminate modalities of intentionality
50 My soul sometimes leaves my body. 2.8, 3.4 Dissociative depersonalization, psychophysical split
62 Parts of my body often have feelings like burning, 3.7 Cenesthetic experiences
tingling, crawling, or like ‘going to sleep’.
74 I have often wished I were a girl. (Or if you 2.9, 2.11 Identity confusion, sense of change in
are a girl) I have never been sorry that I’m a relation to gender
girl. (Scored for F if female)
102 My hardest battles are with myself. 1.9, 2.6, 2.7 Ambivalence, hyperreflectivity, I-split
123 I believe I’m being followed. 02.13.06 Paranoid anxiety
134 At times my thoughts have raced ahead faster 1,3 Thought pressure
than I could speak them.
142 I certainly feel useless at times. 2,1 Diminished sense of basic self
168 There is something wrong with my mind. 1.0–4.5 (Any item)
171 It makes me uncomfortable to put on a stunt 2.13.4 Social anxiety
at a party even when others are doing the
same sort of things.
180 I find it hard to make talk when I meet new 2.12, 2.13.4 Perplexity, social anxiety
people.
182 I am afraid of losing my mind. 1.0–4.5 (Any item)
184 I commonly hear voices without knowing where 1.7.4 Gedankenlautwerden as voices
they come from.
194 I have had attacks in which I could not control 3,7 Cenesthetic experiences
my movements or speech but in which I knew
what was going on around me.
201 I wish I were not so shy. 2.13.4 Social anxiety
211 I can sleep during the day but not at night. 2.4, 2.11.1 Diminished presence, loss of common sense
236 I brood a great deal. 2,6 Hyperreflectivity
278 I have often felt that strangers were looking at 2.13.4, 2.13.6, 5.1 Social anxiety, paranoid anxiety, primary
me critically. self-reference
284 I am sure I am being talked about. 2.13.4, 2.13.6, 5.1 Social anxiety, paranoid anxiety, primary
self-reference
293 Someone has been trying to influence my mind. 1.2, 4.4 Loss of thought ipseity, passivity of mood
312 I dislike having people about me. 2.13.4, 2.13.6, 5.1 Social anxiety, paranoid anxiety, primary
self-reference
332 Sometimes my voice leaves me or changes even 2.3.2, 3.3 Unspecified depersonalization, somatic
though I have no cold. depersonalization
335 I cannot keep my mind on one thing. 1.1, 1.3, 1.6 Thought interference, thought pressure,
ruminations-obsessions
337 I feel anxiety about something or someone 2.13.5 Diffuse, free-floating anxiety
almost all the time.
338 I have certainly had more than my share of 2.6, 2.12, 2.16 Hyperreflectivity, perplexity, anxiety
things to worry about.
345 I often feel as if things were not real. 2.5, 5.5 Derealization, feeling that world is only apparent
349 I have strange and peculiar thoughts. 1.0–4.5 (Any item)
350 I hear strange things when I am alone. 1,7 Gedankenlautwerden
374 At periods my mind seems to work 1.4, 1.11, 1.17 Thought blocking, disturbance in thought
more slowly than usual. initiative/intentionality, disturbance of
expressive language function

Note: All SDO items scored for T (True) except where indicated.
EASE, Examination of Anomalous Self-Experience; MMPI, Minnesota Multiphasic Personality Inventory; SDO, Self-Disorder Scale.

© 2014 The Authors. Early Intervention in Psychiatry published by Wiley Publishing Asia Pty Ltd 5
Premorbid self-disorders and diagnosis

groups (schizophrenia-spectrum diagnosis vs. no
mental illness), nor was there a significant correla-
tion between percentage of missing values and the
SDO scale score.
A correlation analysis comparing the new a priori
SDO scale to other scales previously associated with
schizophrenia revealed moderate to high inter-
correlations among these scales (see Table 3). The
correlation between the SDO scale and Wiggins’ PSY
scale is particularly high (r = 0.864). An item-by-item
comparison of these two scales is given in Table 4.
Our initial hypothesis that the SDO scale would
predict a schizophrenia-spectrum outcome appears
to be supported by the present study. However,
given the high intercorrelation and item overlap
between the SDO scale and the PSY scale, we
needed to investigate whether it was merely the
shared PSY items that accounted for the predictive
efficacy of the SDO scale. In other words, is the SDO
scale only predictive because it contains the PSY
items? To investigate this question, we split the SDO
scale into two subscales: one only containing the 15
shared items (the SDO&PSY subscale) and the other
containing the 17 items unique to the SDO scale
TABLE 2. Descriptive statistics for gender, age and SDO by diag-
nostic group
Variable Group
HR NMI
(n = 64)
Gender (% male/female) 42%/58%
Age at assessment 15.2 ± 2.95
(mean ± SD)
SDO score (mean ± SD) 6.52 ± 4.49
Note: HR, high-risk cohort; NMI, no mental illness at either follow up; SDO,
Self-Disorder Scale; spectrum, broad schizophrenia-spectrum diagnosis at
10-year and/or 25-year follow up.
(the SDO-ONLY subscale.) The ANCOVA analyses
were then rerun for each subscale in turn, with age
of assessment again included as covariate. The Fs
for each overall model were significant (F = 6.96,
P = 0.001 for the SDO&PSY + Age model; F = 4.71,
P = 0.011 for the SDO-ONLY + Age model), but only
the unique items contributed significantly to the
prediction of spectrum diagnosis (F = 3.49, P = NS
for the SDO&PSY main effect; F = 4.32, P = 0.040 for
the SDO-ONLY main effect). Thus, it appears that
there is at least some element of the EASE-analogue
SDO scale that is not merely duplicating previous
MMPI results.
DISCUSSION
The fact that age of first assessment was negatively
correlated with the SDO scale score deserves some
comment. This correlation is probably due to a
selective exclusion of symptomatic, and therefore
most likely older, children at the inception of the
CHRP. In other words, of the children most prone to
develop spectrum disorders (and thus experience a
higher level of SDs), those who were relatively older
at the first assessment were more likely to have
entered their window of symptom onset and thus
have been excluded from the sample, leaving
behind the younger children who had not yet
entered this window.
HR spectrum The main limitation of this study is a rather radical
(n = 68) difference between the nature of the EASE and MMPI
instruments, as noted in the introduction. The MMPI
60%/40%
15.6 ± 2.72 item contents are articulated on a superficial
descriptive level because the focus is on quantitative
8.47 ± 5.84 measurement and automatic categorical decisions,
and therefore more applicable to large-N studies
than to in-depth studies of individual subjects. The
SDO items were selected from the MMPI on the basis

TABLE 3. Intercorrelations between various schizophrenia-related MMPI scales assessed premorbidly in the high-risk sample (n = 185)

MMPI scale MMPI scale

SDO PSY F 4 8 Pz

SDO 1
PSY 0.864*** 1
F 0.612*** 0.702*** 1
4 0.186* 0.247** 0.374*** 1
8 0.820*** 0.799*** 0.650*** 0.402*** 1
Pz 0.761*** 0.873*** 0.642*** 0.294*** 0.752*** 1

*P < 0.05; **P < 0.01; ***P < 0.001.

Note: Pearson’s r coefficients. Prorated raw scale scores used for all MMPI scales.
4, psychopathic deviate; 8, schizophrenia; F, infrequency; MMPI, Minnesota Multiphasic Personality Inventory; PSY, psychoticism scale; Pz, paranoid
schizophrenia; SDO, Self-Disorder Scale.

6 © 2014 The Authors. Early Intervention in Psychiatry published by Wiley Publishing Asia Pty Ltd
 J. Parnas et al.

TABLE 4. Item correspondences between the SDO and the PSY

SDO PSY

MMPI # Item description MMPI # Item description

16 I am sure I get a raw deal from life.

22 At times I have fits of laughing and crying that I cannot
control.
33 I have had very peculiar and strange experiences. 33 I have had very peculiar and strange experiences.
40 Most any time I would rather sit and daydream than to do 40 Most any time I would rather sit and daydream than to do
anything else. anything else.
41 I have had periods of days, weeks or months when I couldn’t
take care of things because I couldn’t ‘get going’.
48 When I am with people I am bothered by hearing very queer 48 When I am with people I am bothered by hearing very queer
things. things.
50 My soul sometimes leaves my body. 50 My soul sometimes leaves my body.
62 Parts of my body often have feelings like burning, tingling,
crawling, or like ‘going to sleep’.
66 I see things or animals or people around me that others do not
see.
73 I am an important person.
74 I have often wished I were a girl. (Or if you are a girl) I have
never been sorry that I’m a girl. (Scored for F if female)
102 My hardest battles are with myself.
123 I believe I’m being followed. 123 I believe I’m being followed.
127 I know who is responsible for most of my troubles.
134 At times my thoughts have raced ahead faster than I could
speak them.
142 I certainly feel useless at times.
151 Someone has been trying to poison me.
168 There is something wrong with my mind. 168 There is something wrong with my mind.
171 It makes me uncomfortable to put on a stunt at a party even
when others are doing the same sort of things.
180 I find it hard to make talk when I meet new people.
182 I am afraid of losing my mind.
184 I commonly hear voices without knowing where they come 184 I commonly hear voices without knowing where they come
from. from.
194 I have had attacks in which I could not control my movements 194 I have had attacks in which I could not control my movements
or speech but in which I knew what was going on around or speech but in which I knew what was going on around
me. me.
198 I daydream very little. [Scored for F]
201 I wish I were not so shy.
211 I can sleep during the day but not at night.
236 I brood a great deal.
278 I have often felt that strangers were looking at me critically. 278 I have often felt that strangers were looking at me critically.
284 I am sure I am being talked about. 284 I am sure I am being talked about.
293 Someone has been trying to influence my mind. 293 Someone has been trying to influence my mind.
299 I think that I feel more intensely than most people do.
312 I dislike having people about me. 312 I dislike having people about me.
332 Sometimes my voice leaves me or changes even though I have
no cold.
335 I cannot keep my mind on one thing.
337 I feel anxiety about something or someone almost all the time.
338 I have certainly had more than my share of things to worry
about.
345 I often feel as if things were not real. 345 I often feel as if things were not real.
347 I have no enemies who really wish to harm me. [Scored for F]
348 I tend to be on my guard with people who are somewhat
more friendly than I expected.
349 I have strange and peculiar thoughts. 349 I have strange and peculiar thoughts.
350 I hear strange things when I am alone. 350 I hear strange things when I am alone.
374 At periods my mind seems to work more slowly than usual.
400 If given the chance I could do some things that would be of
great benefit to the world.
433 I used to have imaginary companions.
448 I am bothered by people outside, on streetcars, in stores, etc.,
watching me.
551 Sometimes I am sure that other people can tell what I am
thinking.

Note: Items listed for PSY scale are only those included in the CHRP 1962 assessment, not the complete item list. All items scored for T (True) except where indicated.
MMPI, Minnesota Multiphasic Personality Inventory; PSY, psychoticism scale; SDO, Self-Disorder Scale.

© 2014 The Authors. Early Intervention in Psychiatry published by Wiley Publishing Asia Pty Ltd 7
Premorbid self-disorders and diagnosis
of a clinical judgment made by an experienced
schizophrenia clinician and researcher who was the
principal author of the EASE scale (JP). Positive
responses to the selected MMPI items were believed
to approximate points in an EASE assessment when a
general complaint would be voiced by the patient
and would then be followed up by an in-depth explo-
ration of the relevant experiential domain. Our accu-
mulated experience from performing the EASE
interviews teaches us that, frequently, the patient
may spontaneously verbalize a non-specific com-
plaint (e.g. headaches, fatigue, depression, lack of
concentration), which, on a more detailed in-depth
exploration, turns out to signify a quite specific
and a qualitatively distinct anomaly of experience
(e.g. thought pressure, hyperreflectivity, sense of
disembodiment, perplexity.) This particular phe-
nomenon, especially important in early or pre-onset
stages of schizophrenia, has been coined in the phe-
nomenological psychiatric literature on schizophre-
nia as a ‘specific non-specificity’.2
However, the question as to whether the SDO
MMPI scale actually taps the kind of experiential
anomalies described in the EASE can only be defini-
tively answered by exploring MMPI–EASE correla-
tions in a sample given by both of these assessments.
We are not aware of any study comparing the MMPI
responses of a schizophrenia-prone sample with
qualitative explorations of their anomalistic subjec-
tive experiences.
Although our design involved contrastive groups
(schizophrenia spectrum vs. no mental illness) and
thus did not allow us to assess specificity, these
results, in conjunction with other available empirical
evidence,17,39 are not inconsistent with the notion of
SDs as a core vulnerability feature in schizophrenia,11
detectable in both the premorbid and the prodromal
stages17 of schizophrenia. Importantly, SDs are
shared by schizophrenia and schizotypal disorders,
with no significant differences between these two
diagnostic groups.11,12,27 In the Copenhagen Linkage
Study, SDs distinguished healthy high-risk individ-
uals who exhibited few schizotypal features from
healthy high-risk subjects with no schizotypal fea-
tures.40 In sum, our results, in conjunction with other
SD studies, strengthen the rationale for a further
exploration of the SDs as a potentially core pheno-
type of schizophrenia-spectrum disorders and its
predictive utility in the prodromal research.17
ACKNOWLEDGEMENTS
The study has been supported by Grant RO1 41469
from NIMH, Bethesda, USA, to Dr J. Parnas.
8 © 2014 The Authors. Early Intervention in Psychiatry published by Wiley Publishing Asia Pty Ltd
REFERENCES
1. Berze J. Die primäre Insuffizienz der psychischen Aktivität.
Leipzig: Franz Deuticke, 1914.
2. Blankenburg W. Der Verlust der natu¨rlichen Selbs-
tverständlichkeit. Ein Beitrag zur Psychopathologie
symptomarmer Schizophrenien. Stuttgart: Enke, 1971.
3. Gruhle H, ed. Schizophrene Grundstimmung (Ich-Störrung).
In: Berze J, Gruhle H. Psychologie der Schizophrenie. Berlin:
Springer Verlag, 1929; 86–94.
4. Jaspers K. General Psychopathology. London: The John
Hopkins University Press, 1963.
5. Kronfeld A. Über schizophrene Veränderungen des
Bewustsseins der Aktivität. Z Gesamte Neurol Psychiatr 1922;
74: 15–68.
6. Minkowski E. La schizophrénie. Psychopathologie des
schizoïdes et des schizophrenes. Paris: Payot, 1927.
7. Parnas J. The core Gestalt of schizophrenia. World Psychiatry
2012; 11: 67–9.
8. Schneider K. Clinical Psychopathology. New York: Grune &
Stratton, 1959.
9. Parnas J, Jansson L, Sass LA, Handest P. Self-experience in
the prodromal phases of schizophrenia: a pilot study of
first admissions. Neurol Psychiatry Brain Res 1998; 6: 107–
16.
10. Moller P, Husby R. The initial prodrome in schizophrenia:
searching for naturalistic core dimensions of experience and
behavior. Schizophr Bull 2000; 26: 217–32.
11. Nordgaard J, Parnas J. Self-disorders and the schizophrenia
spectrum: a study of 100 first hospital admissions. Schizophr
Bull; Epub 29 Jan 2014. doi: 10.1093/schbul/sbt239
12. Parnas J, Handest P, Jansson L, Saebye D. Anomalous sub-
jective experience among first-admitted schizophrenia spec-
trum patients: empirical investigation. Psychopathology
2005; 38: 259–67.
13. Raballo A, Parnas J. The silent side of the spectrum:
schizotypy and the schizotaxic self. Schizophr Bull 2011; 37:
1017–26.
14. Haug E, Lien L, Raballo A et al. Selective aggregation of
self-disorders in first-treatment DSM-IV schizophrenia spec-
trum disorders. J Nerv Ment Dis 2012; 200: 632–6.
15. Parnas J, Handest P, Saebye D, Jansson L. Anomalies of
subjective experience in schizophrenia and psychotic bipolar
illness. Acta Psychiatr Scand 2003; 108: 126–33.
16. Koren D, Reznik N, Adres M et al. Disturbances of basic self
and prodromal symptoms among non-psychotic help-
seeking adolescents. Psychol Med 2013; 43: 1365–76.
17. Nelson B, Thompson A, Yung AR. Basic self-disturbance pre-
dicts psychosis onset in the ultra high risk for psychosis
‘prodromal’ population. Schizophr Bull 2012; 38: 1277–87.
18. Parnas J, Raballo A, Handest P, Jansson L, Vollmer-Larsen A,
Saebye D. Self-experience in the early phases of schizophre-
nia: 5-year follow-up of the Copenhagen Prodromal Study.
World Psychiatry 2011; 10: 200–4.
19. Henriksen MG, Parnas J. Clinical manifestations of self-
disorders and the Gestalt of schizophrenia. Schizophr Bull
2012; 38: 657–60.
20. Parnas J. A disappearing heritage: the clinical core of schizo-
phrenia. Schizophr Bull 2011; 37: 1121–30.
21. Skodlar B, Henriksen MG, Sass LA, Nelson B, Parnas J.
Cognitive-behavioral therapy for schizophrenia: a critical
evaluation of its theoretical framework from a clinical-
phenomenological perspective. Psychopathology 2013; 46:
249–65.
22. Sass LA, Parnas J. Schizophrenia, consciousness, and the self.
Schizophr Bull 2003; 29: 427–44.
23. Parnas J, Moller P, Kircher T et al. EASE: examination of
anomalous self-experience. Psychopathology 2005; 38: 236–
58.

24. Parnas J, Sass LA. The Structure of Self-consciousness in
Schizophrenia. In: Gallagher S, ed. The Oxford Handbook of
the Self. Oxford: Oxford University Press, 2011; 521–46.
25. Moller P, Haug E, Raballo A, Parnas J, Melle I. Examination of
anomalous self-experience in first-episode psychosis:
interrater reliability. Psychopathology 2011; 44: 386–90.
26. Nordgaard J, Parnas P. A semi structured, phenome-
nologically-oriented psychiatric interview: descriptive con-
gruence in assessing anomalous subjective experience and
mental status. Clin Neuropsychiatry 2012; 9: 123–8.
27. Raballo A, Parnas J. Examination of anomalous self-
experience: initial study of the structure of self-disorders in
schizophrenia spectrum. J Nerv Ment Dis 2012; 200: 577–83.
28. Carter JW, Parnas J, Cannon TD, Schulsinger F, Mednick SA.
MMPI variables predictive of schizophrenia in the Copenha-
gen High-Risk Project: a 25-year follow-up. Acta Psychiatr
Scand 1999; 99: 432–40.
29. Bolinsky P, Gottesman I, Nichols D et al. A new MMPI-derived
indicator of liability to develop schizophrenia: evidence from
the New York High-Risk Project. Assessment 2001; 8: 127–43.
30. Niemi L, Suvisaari J, Tuulio-Henriksson A, Lannqvist J. Child-
hood developmental abnormalities in schizophrenia: evi-
dence from high-risk studies. Schiphr Res 2003; 60: 239–58.
31. Parnas J, Cannon TD, Jacobsen B, Schulsinger H, Schulsinger
F, Mednick SA. Lifetime DSM-III-R diagnostic outcomes in the
offspring of schizophrenic mothers. Results from the Copen-
hagen High-Risk Study. Arch Gen Psychiatry 1993; 50: 707–
14.
32. Parnas J, Teasdale TW, Schulsinger H. Institutional rearing
and diagnostic outcome in children of schizophrenic
© 2014 The Authors. Early Intervention in Psychiatry published by Wiley Publishing Asia Pty Ltd
J. Parnas et al.
mothers. A prospective high-risk study. Arch Gen Psychiatry
1985; 42: 762–9.
33. Carter JW, Schulsinger F, Parnas J, Cannon T, Mednick SA. A
multivariate prediction model of schizophrenia. Schizophr
Bull 2002; 28: 649–82.
34. Moldin SO, Rice JP, Gottesman II, Erlenmeyer-Kimling L.
Transmission of a psychometric indicator for liability to
schizophrenia in normal families. Genet Epidemiol 1990; 7:
163–76.
35. Cannon TD, Mednck SA, Parnas J. Antecedents of predomi-
nantly negative- and predominantly positive-symptom
schizophrenia in a high-risk population. Arch Gen Psychiatry
1990; 47: 622–32.
36. Moldin SO, Gottesman II, Erlenmeyer-Kimling L. Searching
for the psychometric boundaries of schizophrenia: evidence
from the New York High-Risk Study. J Abnorm Psychol 1987;
96: 354–63.
37. Moldin SO, Gottesman II, Erlenmeyer-Kimling L. Psychomet-
ric validation of psychiatric diagnoses in the New York High-
Risk Study. Psychiatry Res 1987; 22: 159–77.
38. Moldin SO, Gottesman II, Erlenmeyer-Kimling L, Cornblatt
BA. Psychometric deviance in offspring at risk for schizophre-
nia: I. Initial delineation of a distinct subgroup. Psychiatry Res
1990; 32: 297–310.
39. Koren D, Reznik N, Adres M et al. Disturbances of basic self
and prodromal symptoms among non-psychotic help-
seeking adolescents. Psychol Med 2013; 43: 1365–76.
40. Raballo A, Saebye D, Parnas J. Looking at the schizophrenia
spectrum through the prism of self-disorders: an empirical
study. Schizophr Bull 2011; 37: 344–51.
9