Introduction
A case report of a patient affected by schizophrenia is described. Of interest a disordered Ego emerged with singular features of multiple selves
Materials and method
The patient came under clinical observation at the age of 30 following a psychiatric hospitalization. Initially evaluated in the Emergency Room for panic symptoms, he was prescribed antidepressant therapy. However, a few days later, overwhelmed by deep anguish, he climbed onto the roof of his house with a hammer, intending to strike himself and then jump into the void. While standing on the edge of the roof, he experienced imperative hallucinations urging him to jump, but he managed to resist and abandon his suicidal intent. Later that same day, in a catatonic state, frozen and overwhelmed by voices, he was taken to the hospital and subsequently admitted to the Psychiatric Diagnosis and Treatment Unit (SPDC).
Family history reveals a maternal aunt diagnosed with schizophrenia.
The patient was born at term via cesarean section following an artificially conceived pregnancy. During his high school years, he had a romantic relationship. He completed classical high school but dropped out of university shortly after enrolling.
He worked seasonal jobs. Reported occasional cannabis use for a brief period at the age of 20.
In his remote pathological history, he reports the belief that he was hypnotized by his pediatrician during a pediatric hospitalization at the age of 5 a belief that has persisted to this day. From a personological and psychological perspective, in childhood, he was introverted and solitary. Later, he described himself as precise, meticulous, and introverted, tending to keep everything inside until he “exploded”. During high school, he had an “explosive” and “irritable” temperament, with sudden outbursts: “…I mostly had blood sugar drops… which made me explode”.
On a cognitive level, he has complained of memory difficulties since primary school (e.g., memorizing poems) and concentration. He described himself as unmotivated in his studies but was passionate about philosophy during high school.
According to his parents, during his final year of high school, he went through a “religious crisis”, which led him to quit the Scout group he had been involved with for years and delete all his social media accounts. Around the same time, he developed a strong interest in esotericism.
He arrived at the community mental health service at the age of 29 after a hospitalization in the SPDC.
During clinical interviews with the service psychiatrist (D.R.), the following clinical picture emerged:
Results
Psychopathological Profile
For over 10 years, A. has experienced persistent depressive symptoms that he is unable to shake off. Since then, he has been perceiving auditory hallucinations in the form of voices. Initially, these were simple noises, but over time, they evolved into distinct voices. He distinguishes between external voices and internal voices. He describes two internal voices and others as external:
- An inner Ego that speaks continuously, commenting on his thoughts, actions, and everything he says.
- A second inner voice, which belongs to the people he thinks about. For example, if he thinks about a friend, he hears that friend’s voice asking him why he called him.
- External voices belonging to various people who “constantly say things”.
Around the age of 18, these voices had an abusive content and insulted him, saying things like “…idiot…faggot…if you go out, I’ll kill you…”
He reports that he does not want to communicate his symptoms to his parents because they are not honest with him about the hypnosis he underwent. When he works and focuses, the voices become more specific and more persistent. Sometimes the voices are also present in his dreams, or occasionally, upon waking, a voice comments on his dreams.
One time, he dreamed of being an actor and having to receive an award at an event. During the award ceremony, a discussion arose with the audience, which included several Black people. In the dream, he was arrested, and in the morning, when he woke up, the voice said: “…how can someone get arrested in Uganda?”
The inner Ego voice has a distinct male voice that is different from his own. The other inner voices (“of the people called…”) vary depending on the subject being addressed. Sometimes, the inner voices of the people called argue with the inner Ego. Initially, he believed they were attacking him, but later realized they were simply arguing with each other. Even while driving, he hears voices that seem to give instructions to other cars (“…move aside… hurry up… i need to get to my son…”). Occasionally, he perceives that cars actually respond to these commands and shift accordingly.
BC reports that the inner Ego is located within himself, as if it were a shadow inside his body, taking its shape (like a gas - D.R.’s note).
The inner Ego lives a life of its own. His Ego does not communicate with the inner Ego. Sometimes, the inner Ego says the same things as external people.
The inner Ego seems to be trapped because, at times, it says, “…I need to go home…”
The Inner Ego appeared when BC was 20 years old and gradually developed like a consciousness. However, only shortly before hospitalization did he realize that it was a foreign entity. At first, he thought it was just another voice, but later, he understood its distinct nature. The inner Ego used to insult the other voices. The other inner voices belong to people he hears inside. The inner Ego is like a child who talks constantly and is bothersome. It has an adult voice, as if it were 20-30 years old, but it behaves like a child.
BC tolerates it. He has tried to drive it away, but it always comes back. BC does not talk to the inner Ego. He has tried a few times, but he stopped because it does not listen to him.
“He conducted an experiment. He thought of two parrots that imitate voices. As soon as he thought of the parrots, the inner Ego said: …he wants to make us understand that he knows we are us…”
BC became aware of the presence of the inner Ego at the age of 20, but he believes it had already been there, even though he had never noticed any signs of its presence. The inner Ego is a copy of himself; it always has a male voice that matches his own.
The other inner voices belong to people inside him, but they are not him. These voices, which he describes as “not me”, are internal, distinct from his Ego, and he is unsure whether they are permanently inside him. They are both male and female and only communicate with the inner Ego. The inner Ego, in turn, always talks to the other inner voices.
How do you distinguish the inner Ego from yourself? Because I do not control it. Not even the inner Ego controls it.
Only once was he influenced by the inner voices (not by the inner Ego), and that was when he took drops of Paroxetine and was about to kill himself because the voices were telling him to do so. He does not remember what the inner Ego was saying at that moment. Perhaps the drops had influenced it as well.
If he asks the inner Ego a question, it responds appropriately. For example, when asked, “How old are you?” it answered “21,” but then added “almost 27” and said things that made no sense.
He never asks it questions, and he is not afraid of it.
The multiple Ego and the boundaries of the Self, parallel universes
BC describes visions of “…other versions of himself…” that perform actions and lead parallel lives.
For example, he recounts an experience where “another me” traveled to a space-time projection that appeared as a cube surrounded by “code” (which he describes in computer language, like fractals. Note by BC). Inside this cube, there is a giant man seated on a throne, playing with marbles. The man has five marbles, each representing a different universe. This giant figure is himself in old age, (resembling Popeye), with long white hair and a long beard.
BC emphasizes that these are not dreams but visions that come to him while awake. He has dozens of these memories that seem to appear out of nowhere, as though they were forgotten experiences resurfacing. These flashes (visions) do not frighten him because he perceives them as memories of past lives or parallel lives.
At one point, BC severed ties with acquaintances from the gym because he remembered having done unpleasant things with them in a parallel life, details he refuses to disclose out of fear that he might have to repeat those actions.
These flashes appear suddenly, with no identifiable triggers. They depict a parallel world, as if he were living in two dimensions. He sees these scenes but does not experience them.
The flashes are a parallel world, as if living in two dimensions. He sees these scenes but does not experience them.
An “other me” lived in America when the power was in Apple’s hands. In that life, he worked for the company but was eventually fired after making an error in writing code, which caused the system to crash, leading to his expulsion. (This “other me” is considered another Ego, reinforcing the concept of a multiple Self, n.d.A.).
In October, a notable shift occurred: after several months of treatment with Clozapine (up to 200 mg/day) and Brexpiprazole (4 mg/day), BC reported that he no longer perceived the multiple selves that previously inhabited him.
This improvement emerged gradually over months of Clozapine treatment at 200 mg/day, despite BC voluntarily reducing and eventually discontinuing the medication without offering clinically justifiable reasons (such as excessive sedation, leukocyte count alterations, tachycardia, or other common and distressing side effects).
BC in his relationship with the psychotherapist, has externalized himself as his added Ego and not as BC; it is his added Ego that is the acting subject and it is the added Ego that needs the psychotherapeutic relationship.
This “novelty” leads us to hypothesize an inversion of the Self, that is, the agent-Self protagonist suddenly becomes his added Ego and that he, if need be, and perhaps indifferently returns to himself. Thus, an alternation of the agent subject appears: once he is BC and another time he is his added Ego, in a kind of inversion of the agent Self i.e. an inverted or rather reversible Self.
Therefore, the protagonist and agent Ego of daily life and his added Ego (protagonist of his Ego disturbance) can alternate peacefully coexisting, without confusing each other, but seem to be two faces of the same unique and dual person in the sense of an agent being: an agent Self.
This phenomenon appears to have emerged following the initial therapeutic effects of Clozapine, an antipsychotic known for its potent and targeted action. It is possible that BC’s arbitrary decision to reduce the dosage was influenced by the changes he perceived in his delusional-hallucinatory experience, but perhaps also by the effects on Ego and Self boundaries.
An intriguing aspect of BC’s case is his insistence that medication has not altered his condition. However, clinicians observe noticeable improvements in his facial expressiveness, which is now more in sync and less rigid. His body movements have become less stiff and more fluid.
Additionally, he has agreed to begin a series of sessions with a Psychiatric Rehabilitation Technician (TRP), to whom he has described his rich psychotic symptomatology in great detail. He has also begun sessions with the service’s lead psychologist. Notably, in his sessions with the psychologist, BC speaks exclusively about the experiences of his added Ego, never mentioning himself or his symptoms, just as he does with the psychiatrist and the TRP.
Discussion
Psychopathology of the Ego
According to Jaspers 1 (1988), the ability to distinguish Ego from Non-Ego relies on four formal characteristics:
- Awareness of the Ego as distinct from the external world and others, the ability to recognize what belongs to the Self versus what belongs to the external world.
- Sense of agency and Self-initiated activity, the awareness of being the source of one’s own actions. As Sims 2 argues, this is a form of Self-awareness: if no physical or mental activity occurs, there can be no Self-awareness.
- Continuity of identity over time: the awareness of being the same person throughout time.
- Unity and coherence of Self at any given moment: the ability to consistently recognize oneself as a single, unified individual.
The boundaries of the Ego become indistinct or, as in the present case, they duplicate and, in certain circumstances, multiply. The experience of an entity coexisting with the subject one that determines and influences their will, emotions, and psychosensory perceptions manifests as an autonomously acting entity that is, however, effectively integrated and coherent with the patient. The multiplicity of psychosensory experiences, based on hallucinations and reported to us with detail and clarity, also requires agents that determine, produce, and in some way generate them. For this to occur, a permissive action of a defective Ego is necessary an Ego lacking its usual solidity and consistency, and above all, one with loose and indistinct boundaries, occasionally including external agents. These latter agents take on an almost physical form, appearing as either known or unknown persons. As they break into the existential perimeter of the Ego, they go so far as to engage in conversation or even argue and debate animatedly with the primary entity cohabiting within the person.
In this case, there is a clear disturbance in the boundaries and unity of the Ego. Jaspers, therefore, argues that disturbances of Ego unity should be distinguished from mere hallucinatory representations, such as autoscopic hallucinations, and from personality splits that remain consistent with alternating consciousness. According to the author, one speaks of a true experience of Ego splitting when “the two series of psychic processes develop simultaneously alongside each other, so that one can speak of two personalities, both of which live in a singular manner, in such a way that emotional connections exist within each series, but they do not merge with those of the other side and remain mutually foreign”. *Translated citation from the Italian text*
Phenomena of Ego dissociation may: a) concern an internalized Ego, b) involve the formation of an added Ego as a sort of “double,” or c) manifest as multiple selves, although this issue remains rather elusive in psychopathological literature.
The Ego is thus an internal, organized, individual, subjective, and protective structure that contrasts with what exists externally. In psychopathology, the double is another external person, clearly distinct and different from the acting subject, meaning the subject has an Ego but is not what they claim to be. Therefore, the external person has a different Ego from the one they are supposed to have. However, this psychopathological category does not belong to Ego boundary disorders, even if there are slight phenomenological similarities, but rather falls under misidentification disorders, a category of disorders with a well-established neurocognitive basis.
Further exploration is warranted regarding the fragmentation of Ego unity in relation to delusions of passivity.
According to Tausk 3, Ego dissociation consists of two main characteristics: a) depersonalization and b) dispersonalization. The first includes experiences of estrangement, unreality, and transformation of the Self, body, and world, whereas dispersonalization would actually be a cold form of depersonalization. Delusional experiences of passive influence include: feelings of estrangement concerning parts of one’s own body, mental functions, and ultimately even sensations of transformation. These phenomena are categorized based on whether an identifiable causal agent is present, which may be: a) the patient themselves, b) something within them that does not belong to them, or c) an external causal agent that may become an influencing machine controlled by an enemy. Historically, psychopathology had already proposed and hypothesized the possibility of a duplicated Ego coexisting with the individual experiencing delusions of control and influence.
Conversely, according to Kimura 4, in delusions of passivity, the Ego is not considered a causal agent; rather, it is fundamentally a reflected Self. According to the author, this condition entails a cognitive deconstruction that produces an alterization, meaning that the other agent of thought in delusions of passivity and control emerges because the Ego undergoes a process of Self-reflection. Thus, according to Kimura, there is a “reflection of the Ego in delusions of passivity” that is, Mr. X controls me, but Mr. X is my reflected Ego. In delusions of control, where I control others, it is my agent Ego that exerts influence. Essentially, it is the same agent Ego, which operates either directly or in a reflected form.
Kimura maintains that in understanding Ego disturbances in paranoid schizophrenia, one must consider a cognitive structure underlying paranoid alteration, in the sense that one of the two aspects of the Ego can easily assume the foreignness characteristic of the other. This alteration arises from the side of the reflecting Self, leading to the idea that one is at the center of a delusion of observation and the belief of being watched by others. If, instead, the reflected Ego becomes alien while still maintaining its position as the agent of will, the Self may come to recognize a foreign subject within its most intimate sphere and experience itself as being under the influence of another.
In other words, a condition of Self-oblivion occurs, and the act of i think ceases to function; essentially, it is a case of cognitive disconnection in which the Ego fails in its monitoring function and as a constant agent of our consciousness and experiences. For this to happen, the act of thought and the functions of the Ego, which should essentially remain outside of consciousness, may come back under conscious control and thus become, in some way, influenceable and modifiable. This model clearly reflects the influence of cognitive psychology in understanding the mental basis of passivity and control delusions.
Kurt Schneider 5 considers disturbances in the experience of the Ego highly specific for diagnosing schizophrenia. These disturbances concern either the Ego or the “me”. The first case relates to Egoity, while the second refers to “meity” in the Jaspersian sense 1, meaning that one’s own acts and states are not experienced as Self-generated but are instead guided and influenced by others. This encompasses experiences of thought influence, thought withdrawal, influence over emotions, tendencies, impulses, and will. *Term translated citation from the Italian text*
According to Schneider, Ego disturbances cannot be described in a single, definitive way and remain elusive and unintelligible. The main point emphasized by Schneider is that in the experience of the Ego, one should not rely on knowledge, evaluation, or the reflection of personality. Therefore, one should not speak of Ego consciousness but rather of “speaking of the Ego in its constitutive formal aspects”.
To Jaspers’ 1 four formal criteria of Ego consciousness, Schneider adds a fifth criterion: the consciousness of existence, or the experience of being (ecceity). *Terms translated citation from the Italian text*
He states:
“As long as a person remains conscious, this cannot be erased but only altered, as seen in those in a twilight state or in confusion”. *Translated citation from the Italian text*
This fifth criterion of the experience of being-there in schizophrenic patients persists, albeit in an obscure manner, according to Schneider. Here, it is a pure nihilistic delusion, and this disposition of the Ego is determined by severe alterations of a hallucinatory nature and somatic sensations.
A crucial aspect of diagnosing schizophrenia is that Schneider explicitly identifies first-rank symptoms as highly significant for the disorder’s diagnosis.
He states (Schneider K., 1983):
“Of great diagnostic value in admitting schizophrenia are certain ways of hearing voices: hearing one’s own thoughts (the sound of one’s own thoughts), voices in the form of dialogue and responses, and voices that accompany (and emphasize) the patient’s own speech with commentary”. *Translated citation from the Italian text*
Among thought disorders, he lists thought blocking, flight of ideas, incoherent thought (“zerfahren”), or jumping thinking (“sprunghaft”). It is further cited verbatim: “An extremely important symptom for the diagnosis of schizophrenia is thought withdrawal (“Gedankenentzug”), or even the simple interruption or breaking off of thought”.
Other symptoms assigned a high rank include thought influence, or the suggestion of thoughts, and thought alienation (thought broadcasting), in which other people participate in the content of one’s thoughts (Gedankenausbreitung). Regarding delusions, Schneider highlights as particularly important delusional perception (attributing an abnormal meaning to a real perception) and delusional intuition, which is characterized by “Insights similar to feelings, such as religious or political vocations, the belief in having a special ability, being persecuted, or being the object of someone’s love”. *Translated citation from the Italian text*
Schneider’s psychopathology of the Ego can also be interpreted in the sense that some first-rank symptoms can be viewed “from the common perspective of the permeability of the Ego-environment barrier.” This means that some of these symptoms are extremely important because “there is a loss of Ego boundaries and a fading of its contours”. As a result, the boundaries within which the Ego of each patient lives and develops become much more blurred and indistinct. Among the disturbances that specifically indicate an Ego disturbance are experiences of passivity, such as thought withdrawal, thought influence, and all experiences that are “performed” by others, meaning that they are generated by external agents within the realm of feelings, drives, and will. As previously mentioned, these fall under disorders of mineness (meité) 6.
A further interpretation of the case in question can actually be related to a disturbance of the Ego-consciousness according to Scharfetter 7. This author defines the entity of Ego-consciousness as “the certainty of the vigilant and lucid person: I am myself,” emphasizing that we are conscious of ourselves, in a living body that appears conscious. In his conceptual reference model, he offers certain characteristics that concretely define this Ego-consciousness as an entity with certainty of experience, with a unitary and coherent character, and above all, “defined and distinct from other beings/things”. Furthermore, the model posits five fundamental dimensions of Ego-consciousness: the awareness of being vital and bodily present, the awareness of one’s own experience, the awareness of one’s own coherence and homogeneity, the demarcation of the Ego understood as differentiation and limitation of the Ego. The last dimension pertains to the awareness of one’s own personal, physiognomic, sexual, and biographical identity.
In the present case, a disturbance of Ego activity is present along with a disturbance in consistency and coherence, as well as in the experience of one’s own body:
BC became aware of the presence of the inner Ego at the age of 20, but according to him, it had already existed, even though he had never had signs of its presence. The inner Ego is a copy of himself, has an always-male voice that corresponds to his own. The other inner voices belong to people inside him, but they are not him. These voices, “which are not me”, are internal, distinct from the Ego, and he does not know if they are permanently inside him. They are both male and female and speak only with the inner Ego. The inner Ego always speaks; the other inner voices do not.
(Question): How do you distinguish the inner Ego from yourself? Because I do not control it. Not even the inner Ego controls it. Only once was he influenced by the inner voices (not by the Ego), and that was when he took Paroxetine drops and was about to kill himself because they told him to do so. He does not remember what the Ego said. Perhaps the drops had also influenced him.
It could be argued that, in this case, Ego disturbances are multiple and shape a complex hallucinatory-delusional experience in the sense of an internal yet foreign bodily duplication. The demarcation of the Ego appears loose and unstable, structurally weak, as it allows the intrusion of external agents into its somatic, perceptual, and auditory sensory boundaries.
This picture appears to be changeable and protean in the hallucinatory-delusional experience, where the weight of the delusion is undoubtedly oppressive, accompanied by a faint yet persistent hallucinatory component that never abandons him. We also questioned whether pervasive experiences of depersonalization coexisted, understood in a dual sense both as an unstable distance between the Ego and the Self that is being observed and as a depersonalization of the sense of unreality 7.
Conclusions
In conclusion, although there is little doubt regarding the fracture in reality testing and the concurrent hallucinatory-delusional experience of the patient under study, the psychopathological interpretation appears to be linked to multiple Ego disturbances specifically, a multiple Ego disturbance. This disturbance is governed by several subjects, one of whom is his “added Ego”, while the others are Selves that, nonetheless, play the role of mere figures in this drama that constitutes his experience of reality, momentarily and fleetingly taking part in it.
The definition of the boundaries of the Ego and its structural qualities does not, therefore, appear to be a monothetic concept in psychopathology, and the effort to classify or harmonize what has been observed with the symptomatic constructs of schizophrenia is a titanic task.
This case, for the first time, reports in the field of schizophrenia the description of multiple Egos coexisting within the same person, which disappeared following effective treatment with first- and third-generation antipsychotics: Clozapine and Brexpiprazole.
Funding
None.
Conflict of interest statement
The authors declare no conflict of interest.
Authors’ contribution
DR and VDM made psychopathologival assessment, MB revised the psychopathological assessment and discussion.
