Like Chris Frith, I believe that you cannot have a valid animal model of severe mental illness -- delusions and hallucinations, as far as we know, are not relevant to non-humans. Similarly to Frith, I question the Jasperian hypothesis of schizophrenia as being ‘not understandable.’ As I have noted in previous postings, using the conceptual models of Bolton and Hill [Bolton, D. & Hill, J. (1996). Mind, Meaning, and Mental Disorder: The Nature of Causal Explanation in Psychology and Psychiatry. NY: Oxford University Press], intentionality pervades human biological systems ‘downwards’ to the level of gene expression and genetic structure, e.g., as I noted in various papers: “psychogenic stress in rats (forced cold swims, inescapable foot shock, etc.) led to chromosomal and DNA alterations (using sister chromatid exchanges, unscheduled DNA synthesis as dependent measures) in 2 body cells: leukocytes and bone marrow.” Psychogenic stress can be genotoxic.
Biology includes human interaction, attachment, etc. Neural plasticity is experience-dependent. Therefore psychology (study of intentionality for example) is part of human biology. Disrupted attachments, separations etc. result in dysregulation of various biological systems (see the research of Myron Hofer), which because of various molecular biological changes, e.g., those mediating LTP (long-term potentiation) can last years. As Jeremy Holmes pointed out, attachment processes can be the ‘biological’ basis for psychotherapy.
In addition, non-intentional causes (purely physico-chemical) are ‘taken up’ by intentionality, e.g., in panic disorder ‘normal’ bodily sensations can be catastrophically interpreted and result in increased autonomic arousal.
Daniel Freeman and Philippa Garety (2004) have recently outlined the psychological processes in persecutory delusions (Paranoia: The Psychology of Persecutory Delusions, published in the UK by Psychology Press). Psychoanalysts, such as Harold Searles, Silvano Arieti, Gaetano Benedetti and Herbert Rosenfeld, among many others, have offered compelling psychological renderings of seemingly incomprehensible psychotic symptoms. Franco De Masi, in his new volume Making Death Thinkable, published in 2004 by Free Association Books, underscores the relation between psychosis and death anxiety and disintegration of the personality structure (identity). He quotes Abadi (1984):
“Death, as a disintegration and dissolution of the personality, finds its expression in madness. Madness is a way of representing death to ourselves.”
Psychoanalysts have long noted the problems with identity formation and sense of self in psychosis, e.g., as reflected in such ‘bodily’ boundary symptoms as transitivism and appersonation. One of my long-term patients experiences his body changing into a woman’s body whenever he feels the persecutors are trying to humiliate him or steal his ‘manly’ body out of envy-these experiences are clearly related to actual past traumatic experiences he had with his father and other persons.
Chris Frith (2004), in his “Schizophrenia is a disorder of consciousness” published in Schizophrenia: Challenging the Orthodox, edited by Colm McDonald et al for Taylor & Francis, and in numerous previous research and theoretical papers and books, has cogently analyzed one of the core Schneidarian first rank symptoms of schizophrenia, the delusion of external control. He and his colleagues have done the field a service by challenging reductionistic approaches through his linking mind, brain and body in the understanding of psychotic symptoms. I would also include crucial social factors in this attempt at integration.
Frith makes use of a series of very clever research studies, which examine normal awareness of motor control, to demonstrate the ‘binding’ process which grants individuals a sense of agency and control of actions (from a different perspective, such infant researchers as Colwyn Tevarthen and Dan Stern, have studied this emergent sense of agency from within an attachment and intersubjective paradigm).
Frith predicted that patients with delusions of control would not show a normal attenuation of sensations associated with self-produced movements, i.e., they should be able to tickle themselves (experiencing it as externally caused and therefore responded to with laughter for example). On PET studies, patients with delusions of control evidenced overactivity in the right parietal cortex (this region is thought to be particularly involved in distinguishing actions by other people and actions caused by the self). With ‘normals,’ this area was aroused during passive movements of their hands and arms, while during self-generated movements activity in the parietal cortex was attenuated.
Frith concluded:
“This mechanism of attenuation not only allows one to ignore irrelevant sensory events because they are caused by oneself and are not interesting [e.g., as in trying to tickle oneself], but also is critical for the experience of agency, i.e., the experience of being in control of self-produced actions” (p. 151).
Frith, rightfully so and to his credit, cautions that this area of the parietal cortex might not be structurally abnormal, rather that the overactivity in this area seems to be related to some of the core symptoms of schizophrenia. He speculates that the lack of attenuation in this area may result from the failure of top-down control from some other region, e.g., most likely the prefrontal cortex. He, as many contemporary neuroscience researchers in the field of schizophrenia, appeals to a model of functional neural connectivity in order to explain psychotic symptoms.
My own experience, unlike that of Frith, suggests, that these symptoms of external control, when explored with the patient over time, are significantly associated with relational contexts. Therefore, I would prefer to invoke an intersubjective model (from a neuroscience perspective, noting the significance of mirror neurons and limbic areas mediating fusion, empathy etc, and parietal and prefrontal regions mediating separation, differentiation of internal and external etc.) of delusions of control. One in which the self of the patient can be metaphorically compared to an iron filament for example and the other as a magnet- the experience of self is dominated by and absorbed into the experience of the other (as we see when we do an in-depth psychodynamic study of OCD patients). Medard Boss described this as the Dasein of the patient as falling prey to that which it encounters, the Lacanians as the desire of the Other constituting the patient’s sense of self, Edith Jacobson , Paul Federn, and many others described it as a failure of the establishment of ego boundaries, Fonagy described it as a failure of mentalization in his dialectical model of self-development, Benedetti and Peciccia described it as a de-integration of separate and symbiotic selves, etc. etc.
Separation often seems intolerable and annihilating to the patient, yet as an avoidance of the experience of feeling colonized, constituted and controlled by the other, the patient flees into autistic-like withdrawal and generates self resonance that she or he is psychically alive through such identity maintaining processes as self-referential phenomena, hallucinations and delusions etc. However, the latter, which often reflect a ‘negative’ identity, often reflects the patient’s core difficulties in not being able to be alone or emotionally close to another without the fears of self-loss. Annihilation anxiety, as anxiety in panic patients, becomes part of a vicious cycle in which identity is further threatened and felt to be under siege, i.e., a fragile sense of self and identity both generates a quality of anxiety and panic one could reasonably call annihilation anxiety, and is further eroded by it. Patients are often ashamed of this anxiety and their lack of a cohesive and continuous sense of self, and often try to hide it through interpersonal withdrawal, and, in my experience, are often anxious that their anxiety and concomitant rage and anger, will be destructive to the other should one risk ongoing emotional closeness.
I agree with Frith that the schizophrenias are a disorder of consciousness (a one body model of consciousness). I would add the vital dimension of intersubjectivity (a more two- and three-body model which incorporates social factors). Human consciousness is relationally constituted along the fault lines of schizophrenic breakdown.
Brian Koehler PhD
New York University
80 East 11th Street #339
New York NY 10003
212.533.5687
brian_koehler@psychoanalysis.net
