Consciousness, not only intentionality, yields self-harming behavior

As pointed out by Searle (1987), sub-jectivity and intentionality have alwaysbeen deﬁned as basic characteristics ofconsciousness. Both of them are alsoneeded in order to determine whethera person is a (self-)murderer or not: alegal report of the consciousness stateshould verify whether at that particularmoment a person was subjectively andintentionally able to decide on his/herown actions. Despite the relevance of thisassessment, at the moment the scien-tiﬁc community is not providing a uni-ﬁed deﬁnition of consciousness (Velmans,2009). This lack is particularly relevantfor psychopathology, since consciousnessproblems have been connected to sev-eral clinical pathologies. In the past, veryscarce attention has been paid to theclinical assessment of consciousness, andresearch was mainly devoted to disordersof consciousness. However, assessment ofconsciousness has been acknowledged asbeing extremely relevant for psychiatricpathologies too, as a way of prevent-ing self-harming and suicidal behavior.Several pathologies could result in suici-dal behavior, such as schizophrenia (Boband Mashour, 2011), substance-relateddisorders (Bortelote et al., 2004), post-traumatic stress disorder (O’Brien andNutt, 1998), eating disorders (Favaro andSantonastaso,1995),andothers.Literaturehas usually divided people linked toself-harm into two branches: those whocommitted suicidal actions with a speciﬁcintention (intentional suicides, ISP), andthose who died as a consequence of a riskybehavior,withoutaclearsuicidalintention(risky behavior people, RBP).The ISP sample is mainly composedby people who are/were suffering fromeither major or mixed depressive episodes(Schneider, 2003; Bortelote et al., 2004).These patients usually focus attention onsingle aspects of their perception, con-cerning inner experiences (Ringel, 1953)or circumstances (i.e., confrontation withlifeortraumaticeventsaswellasdevel-opmental tasks: Tschiesner et al., 2012).Patients of this group perceive and elab-orate only speciﬁc contents according totheir symptoms, and this may be viewedalso as a restriction of consciousness(Ringel, 1953; Poldinger, 1968). The con-tent of their phenomenal consciousnessconsists, on the one hand, mainly of emo-tional experiences in many cases ratedmore intense as normal, and, on the otherhand, of a constriction in perceiving alter-native ways of behavior or reaction indifﬁcult situations. Therefore, a dyspho-ric mood characterizes consciousness andtriggers intentions of the same conno-tation, forcing people to direct aggres-sion toward themselves (Ringel, 1953).Rottenberg et al. (2006) have shown thiscongruency between mood and behaviorin depressive patients, a fact that, in turn,wouldexplain whyitissodifﬁcult todefertheir attention from their negative emo-tional status, which could lead them tocarry out suicidal actions. Self-harmingbehavioristhereforeoneoftheaimsofISP,and consistent with, and caused by, theirconstricted consciousness.The RBP category includes people thatare for example looking for thrills doingextreme sports or putting themselvesin dangerous situations, or doing theirofﬁcial jobs like policemen, paramedics,soldiers,orﬁreﬁghters(Goma-i-Freixanet,1995; Tschiesner, 2012). The drive forsituations characterized by novelty andintensity has been described in theSensations Seeking sub-construct “thrilland adventure seeking” (Zuckerman,2007). Sensation-seekers are described asshowingalowlevelofarousal,andtheytryto increase it, in an unconscious way, bydoing extreme sports, consuming drugs,attending religious rituals and so on.This way of controlling arousal throughintense and novel stimuli (Arnett, 1995;Zuckerman, 2007) has been indicated asthe main indirect cause for assuming risksand provoking accidents. Accordingly,Schneider and Rheinberg (2003) arguedthat the aim of risky behavior—by doingrisky activities–is not the danger in itself,but the ability to keep control in dan-gerous situations. Keeping control in adesperate situation like climbing a wallwithout a rope is linked with pleasure(Balint, 1959). Rephrasing, we may saythat RBP seek to manage themselves inextreme situations, in which normal peo-plewouldn’tbeabletodoso.Thisway,RBP are intentionally targeting on theperformance but not the correlated risks,the latter being part of the whole situa-tion,butexcludedfromconsciousanalysis.The access to consciousness is inﬂuenced

As pointed out by Searle (1987), subjectivity and intentionality have always been defined as basic characteristics of consciousness. Both of them are also needed in order to determine whether a person is a (self-)murderer or not: a legal report of the consciousness state should verify whether at that particular moment a person was subjectively and intentionally able to decide on his/her own actions. Despite the relevance of this assessment, at the moment the scientific community is not providing a unified definition of consciousness (Velmans, 2009). This lack is particularly relevant for psychopathology, since consciousness problems have been connected to several clinical pathologies. In the past, very scarce attention has been paid to the clinical assessment of consciousness, and research was mainly devoted to disorders of consciousness. However, assessment of consciousness has been acknowledged as being extremely relevant for psychiatric pathologies too, as a way of preventing self-harming and suicidal behavior. Several pathologies could result in suicidal behavior, such as schizophrenia (Bob and Mashour, 2011), substance-related disorders (Bortelote et al., 2004), posttraumatic stress disorder (O'Brien and Nutt, 1998), eating disorders (Favaro and Santonastaso, 1995), and others. Literature has usually divided people linked to self-harm into two branches: those who committed suicidal actions with a specific intention (intentional suicides, ISP), and those who died as a consequence of a risky behavior, without a clear suicidal intention (risky behavior people, RBP).
The ISP sample is mainly composed by people who are/were suffering from either major or mixed depressive episodes (Schneider, 2003;Bortelote et al., 2004). These patients usually focus attention on single aspects of their perception, concerning inner experiences (Ringel, 1953) or circumstances (i.e., confrontation with life or traumatic events as well as developmental tasks: Tschiesner et al., 2012). Patients of this group perceive and elaborate only specific contents according to their symptoms, and this may be viewed also as a restriction of consciousness (Ringel, 1953;Pöldinger, 1968). The content of their phenomenal consciousness consists, on the one hand, mainly of emotional experiences in many cases rated more intense as normal, and, on the other hand, of a constriction in perceiving alternative ways of behavior or reaction in difficult situations. Therefore, a dysphoric mood characterizes consciousness and triggers intentions of the same connotation, forcing people to direct aggression toward themselves (Ringel, 1953). Rottenberg et al. (2006) have shown this congruency between mood and behavior in depressive patients, a fact that, in turn, would explain why it is so difficult to defer their attention from their negative emotional status, which could lead them to carry out suicidal actions. Self-harming behavior is therefore one of the aims of ISP, and consistent with, and caused by, their constricted consciousness.
The RBP category includes people that are for example looking for thrills doing extreme sports or putting themselves in dangerous situations, or doing their official jobs like policemen, paramedics, soldiers, or firefighters (Gomà-i-Freixanet, 1995;Tschiesner, 2012). The drive for situations characterized by novelty and intensity has been described in the Sensations Seeking sub-construct "thrill and adventure seeking" (Zuckerman, 2007). Sensation-seekers are described as showing a low level of arousal, and they try to increase it, in an unconscious way, by doing extreme sports, consuming drugs, attending religious rituals and so on. This way of controlling arousal through intense and novel stimuli (Arnett, 1995;Zuckerman, 2007) has been indicated as the main indirect cause for assuming risks and provoking accidents. Accordingly, Schneider and Rheinberg (2003) argued that the aim of risky behavior-by doing risky activities-is not the danger in itself, but the ability to keep control in dangerous situations. Keeping control in a desperate situation like climbing a wall without a rope is linked with pleasure (Balint, 1959). Rephrasing, we may say that RBP seek to manage themselves in extreme situations, in which normal people wouldn't be able to do so. This way, RBP are intentionally targeting on the performance but not the correlated risks, the latter being part of the whole situation, but excluded from conscious analysis. The access to consciousness is influenced Frontiers in Human Neuroscience www.frontiersin.org February 2015 | Volume 9 | Article 69 | 1

HUMAN NEUROSCIENCE
Tschiesner and Basso Consciousness, intentionality, and self-harming behavior not only by vigilance (Overgaard and Overgaard, 2010), but also by the content itself: in RBP, only part of the intention is represented within consciousness (the one related to the proximal activity, but not the one related to arousal and to danger). One question that clinical practice poses to basic research concerns the mechanism that selects certain aspects and inhibits others from being accessed by consciousness.
Whereas harm and death in ISP are contents within consciousness, RBP do not include risk as a possible cause of harm or death. The former report to have intentionally attempted to carry out a suicidal action, the latter would deny it. These cases seem to differ with regard to the presence/absence of intentionality. The mood makes the difference: while ISP's mood is characterized by dysphoria and leads to suicidal behavior, RBP's mood is guided by pleasure felt in extreme situations. However, in our opinion, self-harmful behavior in both samples is influenced by the limited content in consciousness and determined by people's affection and needs, not only by vigilance.
The importance of consciousness and intentionality assessment has obvious implications on several applications, such as law (Rigoni et al., 2010). In our opinion, basic research on relevant clinical or subclinical samples like these could be very helpful for elucidating mechanisms of consciousness. In addition, this research would have an immediate impact on assessment and prevention of these self-harming behaviors.