Saturday, May 21, 2011
Schizophrenia a disorder of complexity that is showing disintegration
Over the years after seeing thousands of schizophrenic patients, I feel it is less of an illness and more of a disintegrative process where the person ceases to be a unit. Living organisms are basically conglomerations of ever smaller entities that have their own goals, side by side with the goals of the being as a whole. In schizophrenia the various components of a person start going their own merry way regardless of what is good for him as a whole. It appears that humans once they cross a threshold of complexity cannot prioritize and organize the demands of their various components effectively and a disintegrative process sets in. Schizophrenia appears to be the such a disintegrative process in the mental sphere.
Living organisms constantly, as an evolutionary process, try to accumulate new attributes for better survival. This is done primarily by entering into symbiotic relationship with other living entities. For biological survival is not just about strife with other living organisms but also, when strife with another organism turns into a stalemate, about entering in to cooperative relationships with them, sometimes permanent ones that makes one out of the two. But this cooperative complexity of a living unit can only go to point before the disintegrative process sets in. Schizophrenia appears to be a disorder where due to generations of natural selection the person is born with so many mental drives [attributes] that he fails in the task of giving them proper sequential expression and lets them go their own way.
In a living organism, with increasing complexity, the co-existing subunits have to progressively relinquish, or at least dampen, their own priorities to accommodate the urgency of the entire organism. Without such cooperation and order there would not be harmony in the functioning of the organism as a whole.
An example would be of the digestive and muscular systems. While an organism is hunting a prey, or escaping a predator, the digestive system comes to a standstill. Everything is then about the muscular system; there is no hunger, no thirst, only running and running. After the kill and a satisfying meal, the blood is now primarily directed towards the intestinal tract and the voluntary muscles lose not just their tonus but do so to an extent that immediately after the meal the animal falls asleep.
Even within a system there are subsets which have to accommodate each others' quasi-independence. When the blood flow is to the mouth, gullet and the stomach, during the process of chewing, swallowing and emulsifying food, the lower intestinal tracts come to a standstill. And as a corollary while the person is excreting it has no hunger. This kind of commensalism or mutualism extends to even individual cells. Different parts of a cell must aid and inhibit the functions of cell organelles.
Does such mutualism and what must go necessarily with it, antagonism, exist in the functioning of the mind/brain as well? Since all biological functions are organized on a pyramidal system where even the most refined operations are nothing but a higher complexity of the more fundamental ones, we have to take it as a given that neurological and various mental functions also operate through mutual aiding and inhibiting.
And mental illnesses can be conceptualized as a disturbance in regulation between different mental impulses/functions where some become excessively strong and put undue inhibitions upon others to the detriment of the organism as a whole. That may explain why alteration in the absolute levels of some neurotransmitters brings temporary relief in patient's misery and symptoms without altering the fundamental disease process.
And a little reflection confirms this viewpoint.
In obsessions the sadistic/gouging impulses, executed by the motor system, become predominant, putting inhibitions on other manifestations of libido, while in hysterics other sensory surfaces than the genitals take the center stage in person's love life.
In depression there is general inhibition of all libidinal outlets - which the person had habitually used for finding satisfaction - and he is forced to go in to mourning to put a permanent stop on old ways of satisfaction and find new outlets for his love needs. In mania, the yoke of all the inhibitions is thrown aside - at least temporarily - and all the libidinal outlets become capable of giving satisfaction and the person rushes from one place to another to find objects for his pent up needs - from the earlier period of depression - like a mad man.
It is more interesting as to what happens in schizophrenia.
But before we do that we will have to examine more closely the problem of mania which is most akin to schizophrenia; but easier to understand because a person in its grip is not totally incoherent. The undertaking will come in handy when we finally tackle the more inscrutable schizophrenia.
In mania an attempt is made to allow all of one's needs satisfaction by lifting all inhibitions at once. But on second thought perhaps not all inhibitions. For the manic, despite appearing more crazy than schizophrenic or at least more noticeable - because of his intrusiveness, his great energy that allows him to be all over the place and his desire for attention - is still not quite out of touch with reality. The ego - the central organizing agency - still makes attempts to own up to the person's actions, and still tries to put some order to the expression of the needs of individual components, and still wants to take responsibilities for his actions, and still allows emergence of some guilt over what he is doing, when confronted. The manic's sense of self may become very inflated and megalomaniacal because he is undertaking so many projects at the same time, but it still is there. If the mania causes disorganization beyond a point, the neurochemicals responsible for initiating depression - in all probability acetylcholine - are finally unleashed, and the disintegrative process is reined in by putting a damper on all of one's needs.
In schizophrenia too there is an overwhelming emergence of the pent up needs, but unlike in mania, the ego, the central organizing agency, struggles against them in a most haphazard fashion, and in the end, more or less gives up the struggle, letting the needs aid and inhibit each other more or less independently from the inputs from the ego, which are there, but haphazardly placed, and often contradictory. Schizophrenic has no orderly strategy against the pell-mell emergence of psychic needs. The hurry and the rush of mania is not there because the subunits are pursuing their own course and there is little desire to prioritize. In mania there is still a sense of timing and the person still attempts to go from one need to another, even if he keeps leaving things half done to rush to another project.
The strategy of reining in the excessive satisfaction of needs through depression/inhibitions seen in mania is not done in a sequential manner in schizophrenia. Instead the ego sends the inhibitions in a haphazard fashion and not quite to those precise neuronal activities that would put inhibitions upon the cortical representation of the unruly needs. Acetylcholine, which through its activation of GABA inhibits the cortical activity, in schizophrenia seems to target the wrong areas of cortex. It appears that in schizophrenia an attempt is made to control the excessive demands of the needs by inhibiting not the cortical areas where the memory images of the objects that are required for fulfillment of the need and the motor images of the actions that would get the needs fulfilled are stationed, but by inhibiting the word images that correspond to these objects and these motor actions. Schizophrenia is a disorder where excessive demands are dealt by putting inhibitions upon the cortical areas where word symbols of objects are stationed - the cortical centers of language.
And here lies the essential difference between manic-depressive illness and schizophrenia. In the latter the formation of language itself comes under repression.
I think in those who are destined to turn schizophrenic instead of manic-depressive, the problem lies in the language apparatus. In mania even at the very height of illness, with flight of ideas, klang associations and rapid speech where the words just merge into each other, the words still correspond to the concepts they represent. Words continue to correctly symbolize the "things" they are meant to. Manic person never quite gives up his grip upon the world and the words he uses to understand it. His words do correspond to the ideas he has in his mind and they do correspond to what others believe those sound symbols (words) stand for.
In schizophrenia the language is used in such a manner that there is a disconnect between the words used and the concepts/things they are conventionally meant to represent. There is a modification of the language itself to give into excessive satisfaction of needs. It is a kind of psychogenic aphasia that makes a person behave gibberishly in the social dimension of his life.
Development of the language undoubtedly has played the most important role in making us humans. Language arose as an expansion of auditory signals that evolved to indicate danger. Sounds that dangerous animals or competing humans made, and which spelled danger, began to symbolize these feared objects, and making of these symbolic sounds through the motor apparatus of speech by one person to another could evoke their image in the consciousness even when the feared object was not around. This was the beginning of thought consciousness which makes humans different from other animals. It may be worthwhile in future for me to write here how the sound symbols soon began to be applied from dangerous objects to friendly ones, and then to the objects' actions and their positions in space and time, to their emotional expressions, and finally to abstract notions about them. The latter occurred by doing away their particular attributes and putting them in classes based upon their common attributes. But we will resist here the temptation to get sidetracked into the origin of language itself and limit ourselves to examine as to how language ceases to operate as it should in the disorder of schizophrenia.
And to do that we will have to examine the raison d'etre of mental illnesses itself. It appears that mental illnesses arose because evolutionary pressures forced humans to live in company of those whom they loved and hated at the same time. The object they loved often was the object they hated and hence feared. It is to defend oneself against the fear of those whom we hated but could not get away from because they were the only ones who could satisfy our love needs and who we loved at the same time, did humans develop mental illnesses.
It is our relationship with parents that we first experienced the paradox of having to live in a social milieu where we have to satisfy our love need from the same people who also correct us and who quite often behave punitively and dangerously.
It is the fear of danger to our love life - in boys primarily the fear of castration in hands of the father and in girls the loss of love from the mother - that initiates mental problems. And these adverse consequences from parents, the child senses, would become reality if he or she indulges in unrestrained satisfaction of needs.
There are various ways this fear is nullified, or rather displaced and muted, so the child can continue to love the parents without fearing them. In obsessional neurosis and hysteria the genital activity becomes of secondary importance - comes under inhibition/repression - and the love needs are primarily expressed through prominence of anal-sadistic activities, and sexually loaded exhibition of other parts of the body, respectively. As long as the child does not indulge in the forbidden genital activity that would put him or her in conflict with the parents he need not fear.
But the affect of fear persists. The fear of the father gets displaced upon fear of objects that symbolize him such as thunderstorms or dangerous animals while fear of mother get displaced upon things like closed spaces or witchcraft. The fear is there nevertheless, though in check. As long as the objects and situations that symbolize once feared parents and the circumstances surrounding that fear respectively are not directly faced or reenacted, the fear is under control. And the language apparatus is left undisturbed in these disorders. One person may substitute another in one's thinking, but words continue to symbolize the objects they represent.
In manic-depressive illnesses this imbalance between allowing some needs to be expressed excessively at the expense of others which are inhibited takes on an added dimension. During the depressive phase there is excessive fear and all the needs are suppressed while in mania there is very little fear and an attempt is made to satisfy every possible need. But here too the language is left undisturbed. Words that one uses do not have idiosyncratic meaning, and they mean the same thing to others what they mean to oneself.
Only in schizophrenia the early childhood fears are dealt with by making the words not quite correspond to the objects they represent, and in bringing about other subtle disturbances in the use of language and all because the fear was most profound in this disorder in childhood years when the neuronal tracts of the disorder were laid. Language plays a central role in helping ego put correct inhibitions upon some activities in order to facilitate others. In schizophrenia the yoke of inhibitions falls upon distortion of language areas of cortex.
Why does the language itself becomes the target of inhibition in schizophrenic in contrast to obsessional neurosis and hysteria where other cortical representations of the forbidden objects come under repression instead of just the auditory symbols?
It appears that when an organism reaches a certain degree of complexity it enters into the mode to divide into two separate units. In human this division has to take place by involving another person and via the sexual act. If the complexity becomes too great in a human, due to generations of natural selection, there is increased pressure to prematurely divide and a corresponding premature strengthening of sexuality, and as a consequence greater fear and greater counter measure of repression during the Oedipal phase.
My experience with schizophrenics and those who suffer from schizoptypal speech, they have the greatest difficulty when it comes to talking about sexual processes. The disorganization of language appears to be be some special inhibition in making connections between word representation of sexual organ - the penis - which generalizes to all spheres of language. Yes, once they have psychotic breakdown, or when they are trying to deny the existence of this difficulty, they may be able to bring the words that symbolize these organs without a problem. But even here the proper affect that should emerge when using these words is absent. As if the repression upon the affect of fear gets generalized to all affective expressions.
It appears that the person who is destined to become schizophrenic has disproportionately stronger genital sexual drive at the Oedipal period, causing a massive premature repression that specially falls upon words that symbolize genital organs and the affects associated with it. And this repression gradually generalizes to a whole range of words directly or indirectly connected to the genital organs, causing the language to become highly dysfunctional, finally affecting all those mental functions that must use language areas of the cortex to function in an organized manner.
After such a dry discussion, if anybody has been able to follow the essay this far, he will be glad to get a clinical example of what I am claiming to be the central feature of schizophrenia - a repression of the language areas of the cortex.
A young girl in her twenties who has made a schizophrenic withdrawal from the world due to extreme fear of sexual relations was told in a session that she always sits on the edge of the chair in the office and what could lie behind such vigilance.
It was an indirect broaching of the subject of her extreme caution in giving up her mother - she still lived with her parents - and embracing an extra-familial sexual object. She had dated very briefly in college, and at first hint of having to submit herself sexually, had stopped all interest in men. In fact had dropped out of college.
"Why have you become so cautious?"
The patient thought for some time and when did not reply and was egged to make a response said, "I am questioning about the caution."
After a pause added, "I am wondering about the caution." Then, "I am thinking about the caution." And after another long pause, "I have become so cautioned."
When asked, "What do you mean I have become so cautioned?" She replied, "I am thinking as to what caution is." Then added, "Maybe caution was enlisted by them."
"What do you mean caution was enlisted by them?"
"They saw the caution sign on the road and thought they must be cautioned."
One can see how her sensing that I was broaching the topic of sexuality led this girl to immediately block out the correct meaning of the word 'caution'. By getting confused about the word caution she blocked any further exploration of her conflicts.
A hysteric with a fear of genital sexuality would not have sat so cautiously, but would have been doing just the opposite - acting flamboyant and flagrantly exhibiting her non-genital sexuality. If she had to distort the word caution to avoid further discussion on genital sexuality, she would have either blocked out the word entirely in further conversation, or lisped on it, or mispronounced it, but would have never been confused as to what the word actually means, and how it must be used in understanding complex concepts.
But in my patient, the fear and caution over genital sexuality, when she was confronted about, was handled by getting confused over the meaning of the word 'caution' itself. Under stress, the word had ceased to symbolize the concept which it was supposed to. When words do not symbolize the underlying concepts but become rather fluid in representing a range of related but irrelevant concepts, the patient's grip of reality is grossly affected. For in humans the reality is primarily comprehended by the language system. And this is what happens in schizophrenia, patient gets lost in words when trying to convert experiences into abstract concepts by the aid of language.
Here is another example from the same patient on how language is distorted in schizophrenia. She had an obsession to look inside purses and was creating problem for the family in department stores where she would constantly open every purse she could get hold of and examine minutely what was inside. She even tried to shoplift a couple of specially attractive purses.
As to what lay behind, unconscious to her, was not difficult to decipher. Purse symbolized female genitals and she was looking inside for the missing penis. If it was true that women - at least superior women like mothers - had penis, which was hidden, but could be accessible, then there was no need to take interest in men to get one. One could continue to be attached to the mother and avoid entering into heterosexuality.
One day when I asked her as to how obsession with purses was coming along. Instead of saying I have given it up or it is under control she said, "I lean towards looking at something else."
When asked what do you mean you lean, she said, "If I am attracted towards purses I lean towards looking at something else."
A hysteric would control the impulse to touch the purses by making body movement of leaning away when in the store, or adorn herself with jewelry or other trinkets to compensate for the shiny purse. But in schizophrenic the language itself becomes flowery and elaborate. The world is changed to fulfill ones desires and fantasies not by actual action but by changing the words corresponding to those actions.