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Comprehensive Psychiatry xx (2011) xxx – xxx

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The association between anomalous self-experience and suicidality in

first-episode schizophrenia seems mediated by depression
Elisabeth Haug a,⁎, Ingrid Melle b, c , Ole A. Andreassen b, c , Andrea Raballo d, e, f , Unni Bratlien a ,
Merete Øie a , Lars Lien a, b , Paul Møller g
a
Division of Mental Health, Innlandet Hospital Trust, 2312 Ottestad, Norway
b
Division of Mental Health and Addiction, Oslo University Hospital, 4956 Nydalen, Oslo, Norway
c
Institute of Clinical Medicine, University of Oslo, 4956 Nydalen, Oslo, Norway
d
Department of Psychiatry, Psychiatric Center Hvidovre, University of Copenhagen, 2605 Hvidovre, Denmark
e
Psychiatric Intensive Care Unit, Department of Mental Health, AUSL di Reggio Emilia, 42100 Reggio Emilia, Italy
f
Danish National Research Foundation: Center for Subjectivity Research, 2300 University of Copenhagen
g
Department of Mental Health Research and Development, Division of Mental Health and Addiction,Vestre Viken Hospital Trust, 3004 Drammen, Norway

Abstract

Background: A recent hypothesis is that suicidality in schizophrenia may be linked to the patients' altered basic self-awareness or sense of
self, termed self-disorders (SDs).
Aim: The aim of the study was to investigate whether SDs in first-episode schizophrenia spectrum disorders are related to suicidality and
whether this relationship is independent of or mediated by depression or other standard clinical measures.
Method: Self-disorders were assessed in 49 patients with first-episode schizophrenia by means of the Examination of Anomalous Self-
Experience (EASE) instrument. Symptoms severity and functioning were assessed using the Structured Clinical Interview for the Positive
and Negative Syndrome Scale, Calgary Depression Scale for Schizophrenia, and Global Assessment of Functioning-Split Version.
Suicidality was measured by the Calgary Depression Scale for Schizophrenia item 8.
Results: Analyses detected a significant association between current suicidality, current depression, and SDs as measured by the EASE. The
effect of SDs on suicidal ideation appeared to be mediated by depression.
Conclusion: The interaction between anomalous self-experiences and depression could be a rational clinical target for the prevention of
suicidality in the early phases of schizophrenia and supports the rationale for including assessment of SDs in early intervention efforts.
© 2011 Elsevier Inc. All rights reserved.

1. Introduction appear to have a particular high risk of violent attempts,

Suicidal behavior and subsequent high risk of suicide are
major complications in schizophrenia. The lifetime risk of
suicide in patients diagnosed with the disorder is about 5%
[1], whereas 20% to 30% attempt suicide [2,3]. The risk of
suicide is highest during the early phases of the disorder
[1,4]. Up to 25% of first-contact patients have made 1 or
more previous suicide attempts [5], and untreated patients
This work was supported by Innlandet Hospital Trust (grant no.
150096, 150102, 150119, and 150135), South-East Health Authority (grant
no. 2008058), Eastern Norway Health Authority (grant no. 2004-123, 2006-
258), and European Union Marie Curie Fellowship (grant no. 035975).
⁎ Corresponding author. Tel.: +4795781487; fax:+4762581401.
E-mail address: elisabeth.haug@sykehuset-innlandet.no (E. Haug).
0010-440X/$ – see front matter © 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.comppsych.2011.07.005
emphasizing the importance of early treatment [5-7].
Several predictors of suicidal behavior have been
identified. These include risk factors also seen in the general
population, such as being male, abusing substances, living
alone, being unemployed, being depressed, experiencing
hopelessness, and/or having a history of previous suicidal
ideation/attempts [8-10]. Several of these are more common
in patients with schizophrenia compared with the general
population. Furthermore, risk factors more specific to
patients with psychotic disorders have been identified,
including longer duration of untreated illness, more severe
illness course, nonadherence to treatment, and better insight
[10,11]. The level of positive psychotic symptoms are mostly
found to be unrelated to suicidal behavior [10]. Findings are,
however, not consistent, and risk factors have a low
2 E. Haug et al. / Comprehensive Psychiatry xx (2011) xxx–xxx
predictive power, making it difficult to initiate targeted
suicide prevention in clinical settings.
Risk factors identified until now cannot explain the high
suicide risk in early stages of the disorder. The possible
exception to this is depression, which is more prevalent at this
point of time [12]. Recent studies have thus focused on
patients' subjective experiences, finding that low satisfaction
with life, hopelessness, negative self-appraisals, loneliness,
preserved insight and negative views, and stigma connected
to severe mental disorders are associated with suicidal
behavior in these early stages [7,11,13,14]. These factors
may increase the risk of suicidality not only directly but also
indirectly by increasing the level of depression. In a group of
long-term patients, awareness of psychologic deficits mea-
sured by the Subjective Experience of Deficits in Schizo-
phrenia was associated with depression [15]. This was also
apparent before and after depressive episodes, indicating that
this awareness was associated with vulnerability to depres-
sion and not merely an epiphenomenon based on depressed
patients being more acutely aware of their deficits. The
relationship between subjective experiences and depression
has, however, been studied to a limited extent.
A recent hypothesis is that suicidality may be linked to the
patients' altered sense of self or the anomalous subjective
experiences termed self-disorders (SDs) [13,14]. Self-
disorders are subtle disturbances of the person's spontaneous
experience of himself or herself as a vital subject, naturally
immersed in the world [16,17]. 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 the disorder [18]. A
previous study found significant associations between
important facets of depression (ie, depression, hopelessness,
and ideas of reference ) and the SD-associated phenomena
called basic symptoms [19]. Recently, a qualitative study of
19 patients with chronic schizophrenia found that feelings of
profound solitude, inferiority, and sense of fundamental
inability to relate to others were associated with suicidality
[13]. A later expansion of this sample measuring SDs with
the Examination of Anomalous Self-Experience (EASE)
manual [17] found that suicidality was associated with SDs
mediated through these specific feelings [14].
Our hypothesis is, thus, that suicidality in early phases of
schizophrenia may be partly motivated by SDs either directly
or indirectly through increased feelings of depression. The
aim of the current study is to investigate whether SDs in
first-episode schizophrenia spectrum disorders are related
to suicidality and whether this relationship is independent
of or mediated by depression.
2. Materials and method
2.1. Design and sample
The current study is part of the Norwegian Thematically
Organized Psychosis study and involved all treatment
facilities in 2 neighboring Norwegian counties with a
county-wide population of 375 000 people. Inclusion
criteria were 18 to 65 years old; consecutive in- or
outpatients referred to first adequate treatment for a
Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV) diagnosis of schizophrenia,
schizophreniform disorder, or schizoaffective disorder.
All patients were Norwegian citizens.
Exclusion criteria were the presence of brain injury,
neurodegenerative disorders, or mental retardation. Patients
with concurrent substance use disorders had to demonstrate
at least 1 month without substance use or signs that the
psychotic disorder had started before the onset of significant
substance use (ie, did not meet the criteria for substance-
induced psychotic disorder). Patients were first-contact
patients, that is, they had not previously received adequate
treatment defined as adequate antipsychotic medication for
12 weeks or until remission; some had not yet initiated first
treatment at the time of inclusion to the study. From January
2008 until December 2009, we recruited 49 patients with
schizophrenia spectrum disorders (38 schizophrenia, 9
schizoaffective disorder, and 2 schizophreniform disorder).
All participants gave informed, voluntary, written consent
to participate, and the study was approved by the Regional
Committee for Medical Research Ethics and the Norwegian
Data Inspectorate.
2.2. Clinical assessments
Diagnoses were ascertained by 2 experienced psychia-
trists (EH and UB) using the Structural Clinical Interview for
the DSM-IV [20]. Symptom severity and function were
assessed by standard psychiatric measures including the
Structured Clinical Interview for the Positive and Negative
Syndrome Scale (PANSS) [21]. We used the version of the
Global Assessment of Functioning Scale with assessment
split into symptoms and functioning (Global Assessment of
Functioning-Split Version [GAF-S]) [22,23]. Assessment of
depression and current suicidality was based on the Calgary
Depression Scale for Schizophrenia (CDSS). Current
suicidality was assessed by CDSS item 8 (suicide
thoughts/plans/actions). The measurement of depression
used in our statistical analyses included all CDSS items
with the exception of the suicidality item [24]. Based on
clinical interview and medical charts, we also registered
previous psychotic, depressive, and manic episodes in
addition to previous and current treatment. Duration of
untreated psychosis (DUP) was measured as weeks from
onset of psychosis (first week with symptoms corresponding
to a score of ≥4 on the PANSS items: delusions,
hallucinatory behavior, grandiosity, suspiciousness/persecu-
tion, or unusual thought content) until start of adequate
treatment.
The 2 investigators completed the training and reliability
program of the Norwegian Thematically Organized Psychosis
study group, with Structural Clinical Interview for the DSM-IV
 E. Haug et al. / Comprehensive Psychiatry xx (2011) xxx–xxx 3

training based on the University of California Los Angeles
training program [25]. For DSM-IV, diagnostics, mean overall
κ for the standard diagnosis of training videos was 0.77, and
mean overall κ for a randomly drawn subset of actual study
patients was also 0.77 (95% confidence interval [CI], 0.60-
0.94). Intraclass coefficients (ICC 1.1) for the different
symptom scales were PANSS positive subscale, 0.82 (95%
CI, 0.66-0.94); PANSS negative subscale, 0.76 (95% CI, 0.58-
0.93); PANSS general subscale, 0.73 (95% CI, 0.54-0.90);
GAF-S, 0.86 (95% CI, 0.77-0.92); and GAF function, 0.85
(95% CI, 0.76-0.92).
2.3. Assessment of SDs
Self-disorders were assessed according to the EASE
manual. The EASE focuses specifically on SDs, which are
grouped into 5 domains: (1) cognition and stream of
consciousness, (2) self-awareness and presence, (3) bodily
experiences, (4) demarcation/transitivism, and (5) existential
reorientation. This represents a wide variety of anomalous
self-experiences condensed into 57 main items. Although we
ask questions such as “Have you ever felt as if thoughts in
your head are not really belonging to you?”, such
experiences cannot be assessed by affirmative or denying
responses alone. We need descriptions or examples from the
patients to score the item as present. The interviewer has to
be familiar with the checklist and the distinctions and should
also be experienced in the phenomenology of psychoses to
be sure about targeting not only the plain content but also
structural aspects of self-consciousness.
Each item is scored on a 5-point Likert scale ranging from
0 (definitely absent) to 4 (definitely present, severe level).
For the purpose of the analyses in this article, item scores
were recoded into 0 (absent or questionably present) or 1
(definitely present, all severity levels). The EASE interviews
were all conducted by EH, trained in the administration of
the EASE by one of its authors (PM). The interrater
reliability for the EASE items was examined based on 25
randomly drawn videotaped interviews of first-treatment
patients and examined by PM, blind to diagnostic and other
clinical information. The interrater reliability was found to be
very good, with an overall interrater correlation of the EASE
total score of 0.81 (Spearman ρ, P b .001) and good to
excellent internal consistency across the 2 raters (Cronbach
α N .87) [26]. The patients did not have to be in remission
but were required not be so overtly psychotic that they had
problems participating in a lengthy interview or in
understanding the nature of the informed consent. Each
EASE interview took between 30 and 90 minutes.
2.4. Statistical analyses
All analyses were performed with the statistical package
SPSS, version 15.0 for Windows (SPSS Inc., Chicago, IL).
Mean and SDs are reported for continuous variables and
percentages for categorical variables. Because DUP had a
markedly skewed distribution, median and range values are
reported, and a transformation into its natural logarithm was
used in parametric analyses. We used bivariate correlations
(Pearson r) to evaluate associations between current
suicidality (CDSS item 8), current depression (CDSS total
score minus item 8), and SDs (EASE total score and domain
scores). Regression analyses were used to assess the
independent association between current suicidality, current
depression, and SDs (EASE total score) and also for follow-
up analyses of the effect of possible confounders of their

Table 1
Clinical and demographic characteristics and comparison between nonsuicidal and suicidal
Clinical and demographic characteristics All patients (n = 49) Nonsuicidal (n = 15) Suicidal (n = 34) Statistics
Age, y, mean (SD) 25.8 (7.8) 26.9 (8.7) 25.3 (7.4) Z = −0.55, P = .579
Sex, n (%)
Male 26 (53.1) 9 (34.6) 17 (65.4)
Female 23 (46.9) 6 (26.1) 17 (73.9) χ 2 = 0.11, P = .737
DUP, weeks, median, (range) 122 (4-2040) 156 (4-2040) 113 (5-1560) Z = −0.65, P = .515
GAF, mean (SD)
GAF symptom 33.9 (6.9) 35.5 (4.6) 33.2 (7.6) Z = −0.54, P = .590
GAF function 36.0 (5.5) 35.5 (4.9) 36.2 (5.8) Z = −0.62, P = .534
PANSS, mean (SD)
Positive 19.1 (4.4) 19.5 (5.6) 19.0 (3.9) t = 0.36, P = .726
Negative 17.9 (6.8) 20.7 (6.7) 16.7 (6.5) t = 1.92, P = .066
General 40.5 (8.3) 37.9 (10.1) 41.6 (7.3) t = −1.28, P = .216
Total 76.6 (16.1) 78.2 (18.3) 75.9 (15.3) t = 0.43, P = .672
CDSS total score, mean (SD) 9.5 (5.9) 5.0 (3.1) 11.5 (5.7) t = −5.087, c P b .001
Depression a mean (SD) 8.5 (5.3) 5.0 (3.1) 10.1 (5.4) t = −4.14, c P b .001
EASE total score, mean (SD) 26.0 (9.7) 21.5 (10.5) 27.9 (8.8) t = −2.09, b P = .048
Z indicates Mann-Whitney U test; t, t test.
a
CDSS total score minus item 8.
b
Correlation is significant at the .05 level (2 tailed).
c
Correlation is significant at the .001 level (2 tailed).
4 E. Haug et al. / Comprehensive Psychiatry xx (2011) xxx–xxx

relationship. The results were examined for effect of outliers Table 3

and influential observations. We used the Sobel test to Multiple linear regression analysis with suicidality (CDSS item 8) as the
dependent variable and EASE total score as independent variable,
evaluate mediation. demonstrating mediating effects of depression (CDSS minus item 8)
B P 95% CI
Dependent variable: suicidality
3. Results EASE total score 0.303 a .036 0.002-0.049

Clinical and demographic characteristics are shown in Dependent variable: suicidality

Table 1. Depression 0.623 b b.001 0.061-0.133
In bivariate analyses, patients with high levels of
Dependent variable depression
suicidality had both high levels of SDs (r = 0.303, P = EASE total score 0.405 a .004 0.072-0.366
.036) and high levels of depression (r = 0.623, P b .001)
(Table 2). The EASE total score also had a statistically Dependent variable: suicidality
significant positive association with current depression Depression 0.599 b b.001 0.053-0.133
(r = 0.405, P = .004) (Table 3). There were also statistically EASE total score 0.061 0.634 −0.016 to 0.027.
a
significant associations between the EASE total score and all Correlation is significant at the .05 level (2 tailed).
b
EASE domain scores (1, 2, 3, 4, and 5), whereas all EASE Correlation is significant at the .001 level (2 tailed).
domain scores except domain 5 had a statistically significant
positive association with depression (data not shown in
tables). Finally, the EASE domain 1 (cognition and stream of When combined in a multiple linear regression analysis,
consciousness) and domain 3 (bodily experiences) scores had we found that the association between current suicidality and
a significant positive correlation with current suicidality depression remained statistically significant, whereas the
(Table 2). The main analyses of the current article focus on association with the EASE total score no longer reached the
the EASE total score. level of statistical significance (Table 3). The Sobel test
indicated that the relationship between the EASE total score
Table 2 and suicidality was mediated by the level of depression (P =
Correlations between suicidality and clinical and demographic .05). Follow-up analyses exploring the effects of other key
characteristics (Pearson correlations) psychopathological, clinical, and demographic predictors of
Clinical and Suicidality a Suicidality current suicidality (ie, age, sex, DUP, PANSS subscales, and
demographic dichotiomized b GAF function) did not indicate further confounding effects.
characteristics Because of the statistically significant correlations between
Correlation Correlation
coefficient coefficient current suicidality and EASE domain 1 and 3 scores, we also
(significance, (significance, did follow-up analyses for these domains. The analysis with
2 tailed) 2 tailed)
EASE domain 3 showed the same pattern as for EASE total
Age −0.056 (.708) −0.094 (.520) score (ie, a probable mediation effect of current depression),
DUP ln. transformed 0.030 (.838) −0.105 (.472)
whereas in the analysis with EASE domain 1, it retained its
GAF function −0.088 (.550) 0.065 (.656)
PANSS significant influence even after correcting for levels of
PANSS positive 0.007 (.956) −0.059 (.685) depression. This finding is, however, based on the effect of a
PANSS negative −0.243 (.096) −0.277 (.054) small number of influential cases and should be regarded
PANSS general 0.230 (.116) 0.207 (.154) with caution.
PANSS total 0.010 (.948) −0.067 (.647)
EASE
Total score 0.303 d (.036) 0.310 d (.030)
Domain 1: cognition and 0.330 d (.022) 0.387 e (.006) 4. Discussion
stream of consciousness
Domain 2: self-awareness 0.208 (.157) 0.231 (.111) Our main finding is that of a clear association between
and presence
current suicidality and SDs, which appears to be mediated by
Domain 3: bodily 0.360 d (.012) 0.342 d (.016)
experiences depression. These findings strongly support the role of SDs
Domain 4: demarcation/ 0.255 (.081) 0.172 (.237) in the development of suicidal ideation and behavior in this
transitivism patient group.
Domain 5: existential 0.055 (.710) 0.013 (.931) The association between SDs and suicidality is in line with
reorientation
findings from the study by Skodlar et al [13,14]. The authors
Depression c 0.623 e (b.001) 0.450 e (.001)
a
here suggested that the effect of SDs was mediated by specific
CDSS item 8.
b feelings of inferiority and solitude. They also suggested that
CDSS item 8 (not suicidal vs suicidal thoughts, plans, and actions).
c
CDSS total score minus item 8. these feelings were different from “normal” feelings of low
d
Correlation is significant at the .05 level (2 tailed). self-esteem or loneliness, representing more fundamental
e
Correlation is significant at the .001 level (2 tailed). feelings of being profoundly dissimilar to other people and
 E. Haug et al. / Comprehensive Psychiatry xx (2011) xxx–xxx
thus unable to relate to others. In the current study, the effect
of SDs on suicidal ideation appears to be mediated by
depression. This does not contradict that feelings of solitude
and inferiority could play a role but additionally indicates that
SDs could play an important role in the development of
depression in early phases of schizophrenia [15,19].
5. Limitations
Our cross-sectional design makes it difficult to rule out the
possibility that depressed patients develop and report more
SDs. 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 [15].
6. Conclusion
The present results point to the specific relevance of SDs
to the development of suicidality. The effect of SDs seems,
in turn, to be mediated by depression. This contribute to the
clinical understanding of suicidality in schizophrenia and
suggests that the interaction between SDs and depression
could be a rational clinical target for the prevention of
suicidality in the early phases of schizophrenia and for early
intervention efforts in general.
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