Crisis of objectivity: using a personalized network model to understand maladaptive sensemaking in a patient with psychotic, affective, and obsessive-compulsive symptoms

Abstract

Introduction: Psychiatric comorbidities have proven a consistent challenge. Recent approaches emphasize the need to move away from categorical descriptions of symptom clusters towards a dimensional view of mental disorders. From the perspective of phenomenological psychopathology, this shift is not enough, as a more detailed understanding of patients' lived experience is necessary as well. One phenomenology-informed approach suggests that we can better understand the nature of psychiatric disorders through personalized network models, a comprehensive description of a person's lifeworld in the form of salient nodes and the relationships between them. We present a detailed case study of a patient with multiple comorbidities, maladaptive coping mechanisms, and adverse childhood experiences.

Methods: The case was followed for a period of two years, during which we collected multiple streams of data, ranging from phenomenological interviews, neuropsychological assessments, language analysis, and semi-structured interviews (Examination of Anomalous Self Experience and Examination of Anomalous World Experience). We analytically constructed a personalized network model of his lifeworld.

Results: We identified an experiential category "the crisis of objectivity" as the core psychopathological theme of his lifeworld. It refers to his persistent mistrust towards any information that he obtains that he appraises as originating in his subjectivity. We can developmentally trace the crisis of objectivity to his adverse childhood experience, as well as him experiencing a psychotic episode in earnest. He developed various maladaptive coping mechanisms in order to compensate for his psychotic symptoms. Interestingly, we found correspondence between his subjective reports and other sources of data.

Discussion: Hernan exhibits difficulties in multiple Research Domain Criteria constructs. While we can say that social sensorimotor, positive valence, and negative valence systems dysfunctions are likely associated with primary deficit (originating in his adverse childhood experience), his cognitive symptoms may be tied to his maladaptive coping mechanisms (although, they might be related to his primary disorder as well).

Keywords: RDoC; enactive psychiatry; obsessive compulsive disorder; personalized network model; psychiatric comorbidity; qualitative phenomenology; schizoaffective disorder.

FIGURE 1

Hernan’s personalized network model. Areas in purple denote symptoms. Areas in blue denote patterns of sensemaking. Areas in red denote formative experiences. Areas in green denote biological factors. Areas in yellow denote social factors. Connections are made only between nodes where we can provide explicit data. Nodes are directed, wherein the starting node regulates the target node. +: upregulating node; –: downregulating node; OCS, Obsessive-compulsive symptoms; Anx, Anxiety; P&P, Psychotic symptoms and parasomnias; Fall in SP, Fall in Sunken Place; CoO, Crisis of Objectivity; SM, Sensemaking of himself as a person with mental disorder; RI, Ruminative introspection; ACE, Adverse Childhood Experience.

FIGURE 2

Hernan’s scores on the mini RDoC battery. Green: cognitive systems; red: negative valence systems; blue: positive valence systems; yellow: social processes. Areas with saturated colors denote Hernan’s percentile rank on a given construct. Percentile ranks are represented by colored areas. Hernan’s absolute scores on given constructs are marked with white numerals. Higher values represent greater presence of the psychological function in question; thus scores on SCL, WHODAS, and Barratt were inverted to reflect this principle.