Phenomenology of the social self in the prodrome of psychosis: From perceived negative attitude of others to heightened interpersonal sensitivity


European Psychiatry xxx (2011) xxx–xxx

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EURPSY-2947; No. of Pages 2
Letter to the editor
Phenomenology of the social self in the prodrome of psychosis:
From perceived negative attitude of others to heightened
interpersonal sensitivity

Qualitative changes in the experience of self in relation to
others (i.e. the social self) have been consistently reported to be a
feature of the ‘‘silent’’ initial part of the prodrome [4] and
vulnerability to schizophrenia [2,8]. For example, increased
interpersonal sensitivity, or changes in the felt naturalness of
social interaction, often precedes behavioural manifestations such
as social withdrawal and attenuated negative symptoms [3]. Thus,
early experiential disturbances of social interaction might be an
important early indicator of vulnerability to psychosis in help-
seeking subjects.

The recent report by Salokangas et al. [6] offers crucial empirical
evidence that seems to support this idea. Specifically, it shows that
a not-yet psychotic, paranoia-tinged social sensitivity, consisting
of the subjective experience of negative attitude of others (NAO)
towards oneself, predicts prospective psychotic episodes (over a
follow-up period of 5 years).

The study is a longitudinal hypothesis-testing of previous cross-
sectional findings [7], which revealed an association between NAO
and escalating levels of psychoticism: broad vulnerability to
psychosis, defined by self-reported psychotic-like experiences, and
high risk of psychosis, assessed according to international criteria
for prodromal/at risk mental states (i.e. transient or attenuated
psychotic symptoms; presence of cognitive-perceptual basic
symptoms; putative genetic risk and recent functional decline).

The study holds substantial clinical and conceptual appeal for
several reasons. First, it shows that, although not formally included
among the risk-indicators of transition to psychosis, certain forms
of interpersonal sensitivity are actually predictive of imminent risk
of psychosis.

Second, it coheres with other empirical studies pointing to
certain forms of disturbed intersubjective experience as a feature
of schizophrenia-related psychosis [2,5]. This includes a cluster of
basic symptoms indicative of ‘‘interpersonal vulnerability’’, such as
reduced ability to maintain or initiate social contacts, disturbances
of expressive-emotional responsiveness, increased emotional
reactivity to routine social interactions and unstable feelings of
self-reference [2].

Finally, in our view, the study points to the heuristic value of
adopting a sociorelational perspective in the clinical assessment
of at-risk mental states. Despite the fact that various social
inadequacies are frequently observed in prepsychotic prodromal
phases, our current descriptive-conceptual repertoire is rela-
tively modest, particularly within the field of early detection. In
this context, the closest criteriological notion is attenuated
negative symptoms [3], recently re-emphasized within the
context of ‘‘early and broadly defined psychosis risk mental
states’’ [1].
Please cite this article in press as: Raballo A, Krueger J. Phenomenolo
negative attitude of others to heightened interpersonal sensitivity. E

0924-9338/$ – see front matter � 2011 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.eurpsy.2011.03.003
However, even attenuated negative symptoms, such as initial
interpersonal withdrawal or declining social competences, might
be of limited clinical specificity if only mapped onto the mere
behavioural level (e.g. they can easily be secondary to non-
psychotic psychopathology such as anxiety or depressive dis-
orders). But the same manifestations, when considered within a
phenomenological context—that is, in relation to subtle feelings of
self-reference and an initial paranoid interpersonal sensitivity—
might ultimately be more illuminative of impending psychotic
risk. Nonetheless, besides the ‘‘soft’’ paranoid tainting of social
experiences, other salient experiential changes in the social self are
also worth more focused clinical attention. For example, in the
early prodrome of schizophrenia, the experience of interpersonal
relatedness is often profoundly changed—although not necessarily
in a paranoid configuration. This phenomenological alteration may
exhibit a number of characteristics: a felt sense of loss of
spontaneity (i.e., naturalness) in the very way of relating to and
communicating with others; social hypo-hedonia (i.e. reduced
vital engagement, social drive, a loss of pleasure in interactions
with peers); experienced alterations of intersubjective resonance
(e.g. over-impressionability or fading of empathic feelings towards
others); propensity to de-socializing and solipsistic modes of
experience (e.g. in the sense of alienation from the naturalness of
common sense, or extraordinary, quasi-grandiose feelings of
superhuman capacities and exceptionality, or radical incommuni-
cability and dehumanization) ([4] and [8] for clinical examples). In
our view, this diversity of experiential phenomena calls for a more
systematic clinical focus on the intersubjective manifestations of
vulnerability to psychosis, particularly with respect to the
phenomenological underpinnings of social interaction.

Disclosure of interest

The authors declare that they have no conflicts of interest
concerning this article.

References

[1] Keshavan MS, Delisi LE, Seidman LJ. Early and broadly defined psychosis risk
mental states. Schizophr Res 2011, in press.

[2] Klosterkotter J, Ebel H, Schultze-Lutter F, Steinmeyer EM. Diagnostic validity of
basic symptoms. Eur Arch Psychiatry Clin Neurosci 1996;246(3):147–54.

[3] Lencz T, Smith CW, Auther A, Correll CU, Cornblatt B. Nonspecific and attenu-
ated negative symptoms in patients at clinical high-risk for schizophrenia.
Schizophr Res 2004;68(1):37–48.

[4] Moller P, Husby R. The initial prodrome in schizophrenia: searching for natu-
ralistic core dimensions of experience and behavior. Schizophr Bull 2000;
26(1):217–32.

[5] Oshima K, Okimura T, Yukizane T, Yasumi K, Iwawaki A, Nishikawa T, et al.
Reliability and diagnostic validity for schizophrenia of the Japanese version of
the Bonn Scale for Assessment of Basic Symptoms (BSABS). J Med Dent Sci
2010;57(1):83–94.

[6] Salokangas RK, Patterson P, Heinimaa M, Svirskis T, From T, Vaskelainen L, et al.
Perceived negative attitude of others predicts transition to psychosis in patients
at risk of psychosis. Eur Psychiatry 2011, in press.
gy of the social self in the prodrome of psychosis: From perceived
uropean Psychiatry (2011), doi:10.1016/j.eurpsy.2011.03.003

http://dx.doi.org/10.1016/j.eurpsy.2011.03.003
http://dx.doi.org/10.1016/j.eurpsy.2011.03.003
http://dx.doi.org/10.1016/j.eurpsy.2011.03.003


Letter to the editor / European Psychiatry xxx (2011) xxx–xxx2

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EURPSY-2947; No. of Pages 2
[7] Salokangas RK, Heinimaa M, Svirskis T, Laine T, Huttunen J, Ristkari T, et al.
Perceived negative attitude of others as an early sign of psychosis. Eur Psychia-
try 2009;24(4):233–8.

[8] Stanghellini G. Vulnerability to schizophrenia and lack of common sense.
Schizophr Bull 2000;26(4):775–87.

A. Raballoa,*,b,c, J. Kruegera
aCenter for Subjectivity Research, University of Copenhagen,

Njalsgade 140-142, Building 25, 5th floor, 2300 Copenhagen, Denmark
bDepartment of Psychiatry, Psychiatric Center Hvidovre,

University of Copenhagen, Brøndby, Denmark
Please cite this article in press as: Raballo A, Krueger J. Phenomenolo
negative attitude of others to heightened interpersonal sensitivity. E
cDepartment of Mental Health, AUSL di Reggio Emilia,

Reggio Emilia, Italy

*Corresponding author. Tel.: +45 35328686; fax: +45 35328681
E-mail address: anr@hum.ku.dk (A. Raballo).

Received: 4 March 2011
Accepted: 17 March 2011
gy of the social self in the prodrome of psychosis: From perceived
uropean Psychiatry (2011), doi:10.1016/j.eurpsy.2011.03.003

mailto:anr@hum.ku.dk
http://dx.doi.org/10.1016/j.eurpsy.2011.03.003

	Phenomenology of the social self in the prodrome of psychosis: From perceived negative attitude of others to heightened in...
	Disclosure of interest
	References