To begin with, it is important to keep in mind that the human brain is the most complex organ that we know of. Gerald Edelman (Edelman & Tononi, 2000), Nobel Prize recipient and director of The Neuroscience Institute of Scripps, pointed out that of the 100 billion or so neurons, the cerebral cortex contains about 30 billion and 1 million billion synapses -- the possible number of neural circuits is a factor of 10 followed by at least a million zeros. If we counted each synapse one per second, it would take 32 million years to finish. In regard to the neurogenetics of severe mental illness, the field is divided. There are some geneticists like C. Robert Cloninger who assume a traditional Kraepelinian dichotomy, while others such as Timothy Crow do not (see Elliot Gershon & C. Robert Cloninger edited 1994 text, Genetic Approaches to Mental Disorders, published by the American Psychiatric Press for a good discussion of the involved issues.) In terms of neuroscience and neurobiological research there is often overlap in findings between schizophrenia and bipolar disorder (e.g., ventriculomegaly), but not always (the same being true in regards to the affective and anxiety disorders, e.g., PTSD).
John Strauss, schizophrenia researcher, in his “Is biological psychiatry building on an adequate base? Clinical realities and underlying processes in schizophrenic disorders,” published in Nancy Andreasen’s (ed.) (1994) Schizophrenia: From Mind to Molecule by American Psychiatric Press, stated:
“Through advances in the neurosciences we now recognize numerous transmitter systems, complex structural functional correlates in the brain, and complex changes over time such as lag periods, sequential alterations in brain structure and function, and feedback loops. Such complex mechanisms on one side of the equation are then compared to supposedly stable symptom-based diagnostic categories, static lumps, on the other...The dynamic biologies are anchored to static, simplistic, descriptive notions rather than to the complexity, depth, and dynamism that appear more adequately to describe the real nature of functioning in patients with psychiatric disorders” (p.34).
This position, I think, makes a lot of sense, particularly if one holds to a systems viewpoint. It certainly rings true when I think of all of the persons I am working with or have worked with in the past -- they differ significantly across numerous indices. Also, the problem of psychiatric diagnoses based solely on DSM, despite the formulators’ words of caution, is that they tend to ‘fill,’ or define the person, so we continue to speak of “schizophrenics,” “bipolars” or "borderlines." Parenthetically, I also find the term “schizophrenic brain” to be a category error, as pointed out by Steven Rose, a basic neuroscientist in the UK who has a strong interest in mental illness. This term is very prevalent in the literature, we simply do not diagnose this illness on the basis of neuroimaging scans but rather on the basis of clinical observations and patient self-report (phenomenology). And as Les Havens, following in the tradition of Frieda Fromm-Reichmann, has pointed out, in psychiatry we do not have tests for healthy function, as in other branches of medicine, i.e., in our pathologizing we also need to pay attention to the patient’s strengths and wellness. We need, essentially, to keep our fingers on the pulse of the patient’s personality assets, creativity, resourcefulness etc. Particularly, as cogently pointed out by Harold Searles, to the patient's attempts to have a positive effect/impact on the therapist.
Complexity theory (once called chaos theory) has been usefully applied to the study of schizophrenia by such European clinicians/researchers as Ciompi, Tschaher, Scheier,and Aebi et al in their analysis of the non-linear dynamics of complex systems. Tschacher et al (1997) demonstrated in a considerable number of persons with psychotic symptomatology that Luc Ciompi’s chaos-theoretical approach to schizophrenia was accurate, i.e., productive (positive) symptoms may be generated by a chaotic dynamical system of a few non-linearly coupled variables (e.g., the shame anxiety and mortification arising from a real or anticipated narcissistic injury in a person lacking in a sense of self-possessiveness/autonomy). Clinical observation gives evidence of how heterogeneous the courses of psychotic illnesses can be in the medium or long run. The dynamical concept of disorder allows for no binary judgment between “healthy” and ‘sick” as pointed out in Bion’s concept of the psychotic and non-psychotic part of the personality. Tschacher et al stated: “each person develops his/her own dynamics; psychoses are private and creative phenomena, too, and therefore cannot be subsumed under a category completely” (p. 45). For an in-depth discussion of complexity theory and schizophrenia, as well as systemic, dynamic concepts in severe mental illness, see Hans Brenner, Wolfgang Böker & Ruth Genner (eds.) (1997) Towards a Comprehensive Therapy for Schizophrenia published by Hogrefe & Huber -- there are excellent articles by John Strauss (“Processes of healing and the nature of schizophrenia”), G. Sarwer-Foner (“The humanity of the schizophrenic patient”) and many others in this volume.
I once heard psychoanalyst Philip Bromberg quip that psychiatric diagnoses are a little like airline food, i.e. no matter what you order, they all taste somewhat similar. Edward Hundert (1989) addresses the unity beneath the diversity beneath the unity of symptomatology in persons with a psychotic disorder. Hundert asks: Is it really possible to arrive at a neat distinction between thought (=schizophrenia) and affect(=bipolar)? This may be partially why we have the diagnosis of schizoaffective disorder. For a valuable discussion of the epistemological issues involved and clinical processes in the psychoses see Hundert’s Philosophy, Psychiatry and Neuroscience-Three Approaches to the Mind: A Synthetic Analysis of the Varieties of Human Experience, published in 1989 by Claredon Press, Oxford .
I am one of those clinicians who thinks of schizophrenia as primarily affective illnesses with significant downstream neurocognitive effects (after all, isn’t that how our psychopharmacological agents, such as AP’s, anxiolytics, even AD’s and mood stabilizing agents work, by dampening overwhelming affects?) When I begin to work with someone in psychoanalytic psychotherapy I put aside diagnostic labels. Persons who have become psychotic [whether schizophrenic, bipolar or borderline] have experienced a frightening loss of control over their own mind and worlds, and one of the therapeutic tasks is to help them regain that control, through containment and understanding of how they lost control in the first place, as well as in providing the interpersonal conditions in which the person can integrate what has been dissociated.
When our patient’s sense of self and world begin to crumble and fragment, our first priority is to help them re-establish control, or what Strauss and Davidson have noted: to help patients establish a viable sense of self. This, along with establishing a secure attachment, will ameliorate symptoms. As Hundert (1989) stated, “If this enterprise sounds like an existential struggle of monumental proportions, it is. I only hope we can all find renewed strength to carry out this work with each new patient who offers us the privilege of sharing this noble struggle with them!”
Brian Koehler PhD
New York University
80 East 11th Street , Rm. 339
New York , NY 10003
212 533-5687
brian_koehler@psychoanalysis.net
