The problem of schizophrenia, its mechanisms and treatment is one of the most troublesome in psychiatry. Although far less widespread than other mental illnesses like depression and neuroses, which are now encountered on a mass scale, schizophrenia is what symbolises psychiatry for society at large. Any hint of success in solving this riddle attracts huge attention. It’s not difficult to explain why. To the layman the basic indications of this condition are scary and mystifying. A schizophrenic suddenly goes off into another world, as it were, a world of his own mistaken ideas and absurd, from an outside observer’s point of view, conclusions. Into a world of strange hallucinatory experiences, which the schizophrenic believes to be absolutely genuine. He hears voices inside his head reproaching him for non-existent failings, threatening unthinkable punishments and pushing him into actions which are frequently dangerous both for himself and for those around him. The sufferer is uncritical towards these experiences, he acts according to the hallucinations and deluded, but very persistent, notions, and his behaviour becomes unpredictable.
It may be a paradox, but psychiatry has labelled these delusional ideas and hallucinations as “positive” symptoms. This is not because psychiatrists see anything positive in them, of course, but because they are supplementary, as it were, to the normal life of the psyche and are easily identified during an examination of the patient as ‘add-ons’ to mental activity.
In recent decades psychiatry has acquired medications that can deal with these “positive” symptoms. These are the neuroleptics, which have revolutionised psychiatry. I very nearly wrote ‘successfully deal with’, but stopped in time. Because removing hallucinations and delusions is not a cure of the illness. It’s a cure for society, not for the patient. The suppression of deluded ideas and stifling of hallucinations renders a schizophrenic safe for society, but the patient cannot resume his place as a full member of society, because he still has other symptoms referred to as “negative”, and they may even strengthen.
In this instance, the term is accurate in all respects. On the one hand the word ‘negative’ reflects exactly one particular characteristic of these symptoms. They characterise what the patient is lacking in order to lead a normal life, rather than the ‘superfluous’ aspect of the patient’s behaviour which is captured under the heading of “positive” symptoms. And he lacks a lot: harmony of movement and all the non-verbal behaviour (smiling, inclining the head towards a conversation partner, etc.) which can make even an overweight and generally clumsy individual appear gracious; emotional contact with an interlocutor – the ability to understand another person’s emotions and express one’s own; the ability to perceive the world as an integral whole – schizophrenics perceive the world as fragmented into many small separate pieces and they often become obsessed with details which have little connection with each other. In the same way, they lack that holistic, never wholly realised, perception of self (the self-image) which plays such an important role in the organisation of integral behaviour in healthy people. And so along with these two negative qualities – the absence of a holistic perception of the world and of a holistic perception of the self – there is no sense of harmonious oneness with this world, the feeling of connection to the world with the skin, the pores, all the fibres of one’s being. No sense of that connection which in healthy people has no need of analysis, is not even noticed, like the air, and constantly recharges a person’s vital energy, as Earth did to Antaeus. The absence of this connection naturally leads to the clumsy and discordant behaviour described above. Speech is impoverished, emotions are impoverished, the meaning of existence is castrated. The absence of inner wholeness leads to duality and ambivalence with respect to oneself and the world. Thought gradually becomes slower, more difficult and fragmented.
There really is nothing positive about the negative symptoms, as you can see. What is more, going back to the term “positive symptoms”, we can make a rather paradoxical assertion that while there is, naturally, nothing good about hallucinations and delusions, and the behaviour they dictate is, as a rule, destructive from the point of view of social norms, nevertheless for the schizophrenic himself the appearance of the “positive” symptoms, in contrast to the “negative” symptoms, becomes a way out to a qualitatively different level of life. In a sense it acquires meaning (naturally, one very far from reality, but meaning nevertheless) and becomes affectively rich. A delusional, paranoid idea artificially brings order to and simplifies the world of the schizophrenic. In addition, special studies have shown that in cases where “positive” symptoms dominate, psychosomatic disorders are either absent or diminished.
After analysing all this information, I reached the somewhat unexpected conclusion that there really is something positive about the “positive” symptoms. They reflect a distorted, misdirected, inadequate reality, but also intensive search activity. Are there any facts I can call upon to support my hypothesis?
First of all, psychological analysis of the “positive” symptoms bears this out. You will recall that search activity is activity directed at changing a situation (or a person’s attitude towards it) without any definite prognosis of the results of this activity, but constantly taking the results into account as it goes along. Behaviour governed by delusional ideas falls within this definition.
Thus, a person with a persecution delusion will actively seek ways to evade or destroy his pursuers. He is far from certain about the results of his actions and, consequently, a definite prognosis is out of the question. At the same time, new circumstances arise as a consequence of his (utterly insane) behaviour, come to his attention and are interpreted (in an entirely mistaken way, of course, but accuracy of interpretation is not part of the definition of search behaviour). The person acts in a world distorted by his delusional ideas, but he is active and, furthermore, has no chance of accurately forecasting what will happen next, i.e. in conditions of uncertainty. The same is true of any other delusion, distorted perception of reality or paranoid behaviour.
Until very recently it was harder to explain the ‘search’ nature of aural hallucinations, which are typical in schizophrenia. It seemed that the perception of hallucinations was definitely a relatively passive process, though I tried to get around this by stressing the active character of the attention to hallucinations and the active nature of the behaviour stimulated by them. However, at the last minute new data confirming the active nature of the hallucinations themselves came to the rescue. In a study of the metabolism of the brain at the moment hallucinations were experienced, researchers found that the most active areas of the brain were not those linked with the perception of speech, but those associated with the active production of speech. This means that aural hallucinations are a form of active speech behaviour. This explains, too, the many instances of ‘inner dialogue’ during hallucinations.
Yet arguments in favour of the ‘search’ origin of hallucinations and delusions are not confined to psychological analysis. The results of research into the sleep of schizophrenics also provide strong support. It has been shown that when “positive” symptoms dominate, the need for REM sleep, with accompanying dreams, drops. This stage of sleep diminishes without a subsequent ‘recoil effect’, i.e. without a compensatory increase after the suppression of “positive” symptoms. This leads us to the straightforward conclusion that the need for REM sleep against a background of hallucinations and delusions is reduced. At the same time, our earlier research showed that REM sleep increases with renunciation of search, with capitulation, and diminishes with pronounced search activity during the preceding state of wakefulness. In fact, the task of REM sleep is to restore search activity, and when this task is unnecessary, the need for REM sleep diminishes.
When “negative” symptoms dominate, the proportion of REM sleep during the night is greater than with “positive” symptoms. It also increases if “positive” symptoms are suppressed with neuroleptics.
The action mechanism of neuroleptics provides further support for my concept. It is assumed that neuroleptics block the receptors of the catecholamine systems in the brain, thereby reducing the activity of these systems, which is increased in schizophrenia. (Among the catecholamines are neuro-mediators such as dopamine, adrenaline, noradrenaline and others, which assist the transmission of nerve impulses in the central nervous system.) However, according to the concept of search activity, search behaviour requires a high level of cerebral catecholamines to exist and is able to support this high level of catecholamines on its own through the positive feedback mechanism.
Blocking the exchange of catecholamines in the brain by medication suppresses search activity. This is exactly what happens with the use of neuroleptics: incorrectly oriented search activity which gives rise to “positive” symptoms is suppressed, but so are all other forms of search activity as well. Not surprisingly, systematic use of neuroleptics frequently leads to depression, apathy and a deepening of negative symptoms.
In a series of experiments I carried out with Professor Arshavsky on animals, we showed that use of neuroleptics leads to side-effects in the neuromuscular system (tenseness, trembling, Parkinsons-like symptoms) especially quickly in those cases where renunciation of search is provoked by direct stimulation of the brain. If search behaviour was provoked, the neuroleptics did not produce these side-effects, even though they have a tendency to block the brain’s catecholamine systems in those zones responsible for muscle tone and motor behaviour. In natural conditions neuroleptics have a double action: they create the conditions for all kinds of somatic pathology by suppressing the activity of cerebral catecholamine systems in general, and they determine the development of Parkinsons-like complications against this background by blocking the catecholamine systems in the corresponding subcortical zones of the brain.
However, the notion of distorted search as a mechanism of “positive” symptoms in schizophrenia does not explain why this incorrectly oriented search happens. For an answer to this question we need to look at the problem of inter-hemisphere asymmetry.
The particulars of inter-hemisphere asymmetry in schizophrenia have long been the subject of hot debate in the scientific community. Two competing hypotheses have emerged. One that has attracted wide support was advanced by Professor Pierre Flor-Henry. According to his hypothesis, schizophrenia is characterised by dysfunction of the brain’s left hemisphere. Experiments by Dr. Ruben Gur and others showed that when “positive” symptoms are dominant, electrophysiological and functional hyperactivity are seen in the left hemisphere. This fits in well with the dominant role of the left hemisphere in speech production, since, as I noted earlier, the aural hallucinations typical of schizophrenia are a kind of inner speech and reflect the activity of those left-hemisphere mechanisms responsible for speech production.
This hypothesis might also explain the formation of delusional ideas with a poor connection to reality. Experiments by Professor Deglin and his team showed that temporarily switching off the right hemisphere using ECT leads to a dominance of formal logic totally divorced from reality. The left hemisphere is capable of isolating itself from reality and concerning itself solely with ensuring there are no formal internal contradictions. Delusional ideas share the same underlying principle. They are usually internally consistent, have no contradictions, and sometimes display an elegant and elaborate logic within the framework of the absurd system allocated to them.
However, if excessive activation of the left hemisphere can explain hallucinations and delusions, it is much harder using this to account for impoverishment of speech and thinking, its fragmentation and the breakdown of probabilistic prognosis. We know that probabilistic prognosis is a function of the left hemisphere, and so it is more natural to suppose that it will be impaired by suppression of left-hemisphere activity rather than by over-activity. Also, Professor Joseph Feygenberg has shown that a breakdown of probabilistic prognosis (the inability to use past experience to make an adequate forecast of subsequent events) is characteristic of schizophrenia. The results of many other psychological studies (for example, a lack of so-called latent inhibition, when already existing information is not used to decide a subsequent behavioral strategy) can be interpreted the same way and, we should note, this phenomenon is most frequently encountered when “positive” symptoms predominate. Here we are confronted by a logical contradiction. The symptoms are evidence simultaneously both of increased left-hemisphere activity and of its active suppression.
Finally, the hypothesis of a hyperactive left hemisphere provides no explanation for schizophrenia’s negative symptoms. It also leaves unexplained some components which are a constant feature of the illness such as motor disharmony, weakened emotional reactions and contacts, the inability to grasp a holistic image, a seriously deficient self-image, the inability to perceive spatial and visual information adequately and to express emotions in behaviour. As it happens, we are able to explain all these symptoms as deficiencies of the right hemisphere, and a concept along these lines was proposed by Professor John Cutting. However, it, too, suffers from one-sidedness, as it does not explain the origins of schizophrenia’s “positive” symptoms. It’s tempting to join both concepts together, but this can’t be done in a formal, mechanistic way. If we do that, we still can’t understand what are the inner correlations and causal relationships between suppressing the functions of the right hemisphere and the hyperactivity of the left. We still won’t have resolved the paradox I noted earlier of why a hyperactive left hemisphere does not perform its functions with regard to probabilistic prognosis.
In my efforts to overcome these contradictions I proposed the following hypothesis. A deficit of right-hemisphere thinking, an inability to organise polysemantic context, is the root cause of schizophrenia and explains all the negative symptoms described earlier. Central to this whole conglomerate is the inability to form a multifaceted, polysemantic self-image, harmonious in its polysemy. This amorphousness of the self-image manifests itself in behaviour as a whole, first and foremost in clumsy, inharmonious non-verbal behaviour, as the self-image is the central regulator of behaviour.
Amorphousness of the self-image and inadequate thinking in images negatively impact the psychological defence mechanisms. The right hemisphere can’t ‘grab’ and evaluate information before it is realised and so protect the consciousness from unacceptable information. As a result, the consciousness ‘drowns’ in information it cannot handle.
Let’s go back to the problem of aural hallucinations. If they reflect a schizophrenic’s inner speech, why is this inner speech ascribed to another person? For our actions (and our speech) to be perceived by us as initiated by us, they have to be an integral part of the holistic idea of ourselves. They have to be part of the self-image which defines our behaviour. If this image is fragmentary, then individual actions and thoughts can be perceived by us as not belonging to us, as generated by some external force. Going further, there are grounds for supposing that our inner speech is the organisation of verbal material governed by the laws of polysemantic thinking, which is defective in ill people. Alienation from one’s own inner speech is not exceptional in the clinical picture of schizophrenia. Sufferers often perceive both that their own actions are imposed by someone from outside and feel like robots performing someone else’s wishes and working to a program that is not theirs. The following point is of interest in this regard. Observation of the emotional reaction of schizophrenics to their aural hallucinations led to the idea that natural sounds or human speech evoke lively images in them. But further studies showed either there is no link between the ‘liveliness’ of aural images and a predisposition to aural hallucinations or the link is opposite in character – the stronger the hallucinations, the less ‘lively’ the aural images in everyday life.
What is the cause of dysfunction of right-hemisphere thinking? I believe the prime cause is a lack of emotional contact with parents in early childhood. Emotional relations are polysemantic by nature and so assist the development of polysemantic thinking in images. According to Günther Ammon, Melanie Klein and other leading psychoanalysts, patients suffering from mental and psychosomatic illnesses reveal a systematic deficit in emotional contact in early childhood. The whole of Western civilization and its education system also promote the development of the left hemisphere at the expense of the right.
If the ability to form polysemantic context is not developed and, as a result, a person loses all the advantages of this means of adapting to the world and integrating into it naturally, then he is forced to resort to other means of adaptation. He tries to remedy the deficiency by ever greater efforts to order and structure reality, i.e. by activating the left hemisphere. The left hemisphere already has quite sufficient inclination to being excessively active, as I have shown in earlier chapters. Its hyper-compensatory activity is always a physiological hyper-activation and the left hemisphere is closer to the activating mechanisms of the brainstem. If this weren’t enough, the person, and the people around him, push the left hemisphere to excessive activity. Seeing that the child or youth is stronger in the sciences than the subjects that require thinking in images, the people closest to him, instead of trying to remedy the deficit, begin to exploit ruthlessly those abilities and tendencies that are already there in excess. This goes on until the left hemisphere, without a balance of sobriety and vitality from the right, finally tears free from reality and soars up into a stratosphere of delusion and hallucination. When all a person’s search activity is based solely on the resources of monosemantic context, he becomes self-absorbed and self-reinforcing.
If a person is completely enclosed in the artificial world of his own hallucinations and delusions, the left-hemisphere mechanisms responsible for probabilistic prognosis simply do not have the equipment to evaluate reality adequately, and for this reason probabilistic prognosis and the use of past experience suffer where “positive” symptoms are present. If we put the question like this, then there is no contradiction between heightened activity of the left hemisphere and its functional inadequacy: simply, the hyperactivity is oriented towards an unreal world, while functional inadequacy relates to the real world, and both these worlds are in competition with each other.
So, what conclusions can we draw from all the above about the treatment and rehabilitation of schizophrenia patients? It is not enough to use medication to suppress the “positive” symptoms (and search activity with them). The necessary conditions have to be created for the reorganisation of search activity, for it to be directed normally. What is needed for that is, first of all, a functional ‘unloading’ of the left hemisphere. This can be done, by using every possible means to activate the right hemisphere (supportive emotional contacts, development of creative potential, artistic activities and so on). In Israel a rehabilitation centre focused on realising patients’ creative drive, following the example of Günther Ammon’s clinic in Germany, has been in operation for a little while now, and the initial results of that work have been encouraging.