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News Gram™ October 2003

October 2003 ~ Vol. 10, No. 3

One of the more interesting areas of psychiatry has to do with something called the self. Another word for the self, roughly, is ego, which has a technical connotation. We can treat the self as an entity that has both a subjective and objective dimension - an inside and an outside. How the brain actually produces a sense of self is a complex process. Also, when the central nervous system fails to operate properly, the ordinary awareness a person has of himself or herself may be disturbed. It's worth looking at some syndromes in which a disturbance of the self is involved, since it tells us a lot about the brain and ourselves.

Before doing that, let's take a look at one conception of how the self develops. In the first year of life, the self consists largely of an awareness of bodily states - pain, hunger, wetness. Between the first and third years, the child develops a sense of self-differentiation, i.e. an awareness of other people (or selves) who are distinct from him. For the next seven years there is an emerging awareness of relationships, role in the family, as well as a more nuanced appreciation of self based on how others may see the child. During puberty, the issue of self-image assumes substantial proportions and by 18 years of age, it is integrated into a more mature sense of how one fits in with other people and institutions.

Interestingly, psychiatric syndromes often contain disorders of the self that are not fully appreciated. Let's take a look at some of them:

Impairment of the sense of personal existence - For most people, there is no doubt as to whether or not one exists. We take such an idea as the most self-evident aspect of ourselves and rarely consider its opposite. In some syndromes, however, especially affective disorders, an individual may actually experience a diminished sense that he or she exists. We sometimes refer to such a state as a nihilistic delusion. In severe depressions, people may have the sense that they simply don't exist. On a less intense level, we find patients who have a sense of depersonalization, a feeling that they are not as real as they had been in the past. It is as if the person's sense of self thins out.

Disorder of activity - When we do something, we experience ourselves doing it. Sometimes a person's awareness of doing something may become attenuated. For instance, a patient may feel that she is not the one perceiving a certain scene. She may remark that her experience is like a dream. We might say that a person doesn't feel as in charge of herself as she usually does. Sometimes there is a loss of feeling or emotional fullness. Finally, there can be a sense of not being able to will an act; this state of mind represents a profound sense of powerlessness.

Disorder of singleness - We take it for granted that we are a single, unique entity with a name and an identity. On occasion, though, a person may not have the experience of being an integrated unity. He may see himself as if from the outside. This syndrome can take a series of different forms: There is autoscopy, for instance, in which a person sees himself. He is not alarmed and tends to be almost indifferent to what he is viewing. One definition of autoscopy is that it is "a complex psychosensorial hallucinatory perception of one's own body image projected into the external visual space."

The doppelg‰nger phenomenon consists of an awareness of oneself as being both outside oneself and inside oneself. This symptom may be a form of depersonalization. It is important to distinguish it from autoscopy, which is a perceptual disorder, since the doppelg‰nger phenomenon is cognitive in nature. The person believes his double is outside or alongside him. This rare, severe phenomenon is usually associated with some degree of impaired consciousness.

Disorder of identity - Most people have the impression that they are the same person as the one who occupied this body a month, a year, a decade ago. Sometimes, though, that impression is lost and the individual has the experience of himself as someone who is not the same person as before. There is a sense of discontinuity in the patient. Just as an individual may not feel as if he is an integrated whole at one particular time, someone may have the impression that he is not integrated over time.

We have some ideas about what causes such disruption in such a fundamental aspect of our existence. The most likely culprit in these syndromes - though hardly the only one - is an impaired parietal lobe. That part of the cerebral cortex integrates multiple sensory inputs and a disruption in its functioning can produce the kinds of disorders described above.

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