In light of recent postings on our listserve, I am re-posting the following comments:
Schizophrenic Symptoms, Separation Panic & Seeking
It occurs to me that there is a significant connection between the productive-positive symptomatology of schizophrenia, such as delusions and hallucinations, and the negative symptoms, such as anhedonia, alogia, anergia etc, that is held together by the psychoneurobiological systems mediating attachment, separation and seeking, as well as dreaming. Freud’s concept of decathexis-recathexis (which Ping-Nie Pao in his 1979 volume “Schizophrenic Disorders” pointed out never gets adequately resolved in persons with schizophrenia) touches on these psychoneurodynamic processes. Freud believed, in brief (and I do not do justice here to the complexities and implications of Freud’s views), that delusions are like patches placed over the tear/gap formed between the ego and world as a result of withdrawal of psychic investment secondary to a narcissistic injury, that positive symptoms are restitutional, and that the withdrawal of investment (negative symptoms) initiated the ‘disease’ process. Freud understood the difficulties that the psychotic person has in separating one’s ego from the world (other people).
Pao understood psychotic symptoms as the best possible solution to the problematic of organismic panic in inadequately differentiated (perhaps in Fonagy’s terms, impaired mentalization and primary internalization of the alien object as opposed to secondary representations of the child’s affect states mediated through the environment) individuals engaged in a pathological reorganization of the self (e.g., grandiosity, paranoid stance) in order to ensure continuity and cohesion. Absence of the primary object which confers the ability to mentalize one’s affects and self states drives the person to seeking (separation-distress call) a sense of connection (e.g. hallucinations & delusions) with the primary object and dreaming (I have noticed when my patients diagnosed with schizophrenia begin to recover they report more dreams, perhaps because dreams feel too psychotic with little differentiation between internal & external reality, or as Bion thought, impaired containment leads to massive evacuation of the elements that are precursors to dreaming, i.e., beta elements- I was so pleased when after 6 years of intensive psychotherapy one of my patients reported his first dream - Franco De Masi recently published an interesting article on dreams & psychosis in the International Journal of Psychoanalysis).
Psychotic symptoms could be understood as part of the seeking and panic psychoneurobiological systems. Positive symptoms as part of the over-aroused seeking system and negative symptoms as a cessation of seeking-both triggered by the fear and panic systems. To understand these ideas, a review of these systems is contained in Mark Solms & Oliver Turnbull’s (2002) “The Brain and the Inner World: An Introduction to the Neuroscience of Subjective Experience,” published by Other Press. Briefly, the seeking system originates in cells of the VTA (dopaminergic-ventral tegmental area) and fans out to the dorsolateral hypothalamus, the nucleus accubens, amygdala, the anterior cingulate gyrus (on PET this area lights up in attachment, auditory hallucinations, etc), and other cortical areas in the frontal lobes. The seeking system forms part of the mesocortical-mesolimbic DA system-which many believe is involved in the generation of psychosis and the therapeutic activity of antipsychotic agents. Overactivation of the seeking system leads to the positive symptoms of schizophrenia and psychosis. Damage (or as I would see it in many instances, functional deactivation to ensure continuity and cohesion of the self) to the seeking system causes individuals to loose interest (decathexis) in objects of the world, dreaming ceases and positive symptoms (hallucinations & delusions ) may decrease.
In brief, the panic (or what Solms & Turnbull refer to as separation-distress) system is associated with organismic panic (Mahler, Pao) as well as feelings of loss and depression. Solms & Turnbull state: “This provides neuroscientific evidence for the link that psychoanalysts have long recognized between panic attacks, separation anxiety, and depressive affect. The operation of this system seems to be intimately connected with social bonding...” The psychoneurobiological core of this system is the anterior cingulate gyrus which connects with several thalamic, hypothalamic, and other nuclei (such as the bed nucleus of the stria terminalis-BNST, preoptic hypothalamus (which recent research has demonstrated a great deal of neuroplasticity during maternal feeding, i.e., the mother’s cells are altered by feeding her infant) as well as the ventral tegmental area (implicated in schizophrenia). These areas also connect to PAG (periaqueductal gray area). Stimulation of this system causes the separation call (see Paul Maclean’s analysis of the separation call for its relevance to human psychopathology). Hypothetically, this would increase the chance of locating or being located by the primary object (sometimes I wonder if hallucinations and delusions are a form of the separation call?). If this is not successful, the organism displays a form of withdrawal and hibernation (negative symptoms? and in extreme forms, catatanoid symptoms - it is of more than passing interest that Sullivan understood catatonia to be the primary symptom of schizophrenia) that looks like depression. Perhaps,this behavior has been selected in our evolution to minimize the risk of predation if one were to seek too long without protection.
As Harold Searles (in “Transitional Phenomena and Therapeutic Symbiosis”-in his 1979 volume “Countertransference and Related Subjects”) so cogently suggested, psychotic symptoms must become transitional objects (see Winnicott on transitional objects & phenomena) for both patient & therapist (Benedetti has made similar observations over his 50+ years of psychotherapy experience) in any successful psychotherapy of persons with schizophrenia. Parenthetically, opiates reduce the separation call in mammals (is this one reason why are patients use heroin, etc to self medicate their separation panic?).
I would like to use recent clinical material from my practice to illustrate and flesh out these conjectures and psychoneurodynamic processes (always with the aim of countering the unfortunate reductionism gripping our field ever more increasingly). For reasons of confidentiality, I am forced to omit certain material which would further support my hypotheses of the crucial role of subjectivity & intersubjectivity in not only the course, but the origins of the human illnesses we call schizophrenia. In brief, the patient, a highly intelligent (see L. Sass concept of hyper-reflexivity in certain forms of schizophrenia) young woman suddenly finds herself entangled in delusions of being the target of an assassination attempt. This occurs within the context of several separations of symbolic importance (persecutory & depressive guilt/anxiety played a key role). After the delusions are resolved through psychopharmacologic agents (which are gradually being reduced as the psychotherapy continues to have a positive effect on the panic and attachment systems) and psychotherapy, the patient has a worrisome (to the patient and family) sx of excessive seeking of the primary object (this phenomenon was normalized as a result of, among many others, Bowlby’s pioneering work on separation distress). This creates a great deal of shame for the patient and self hatred, especially since it resulted in a significant scaling back of her life plans. I believe the seeking (arising from what Benedetti called the narcissistic gap or Fonagy’s impaired mentalization of one’s own affect states as well as that of the other) system went into overdrive as a result of activation of the panic-separation system which was elaborated further through painful feelings of unconscious guilt about being destructive to significant others.
The delusion was a form of signal, a disguised separation call which remained in a less psychotic form as a result of therapeutic intervention. The delusion of being a target of assassination may be related to Bion’s concept of the absent object becoming a persecutory, hostile presence (it is important to emphasize that the absent object is a complex concept perhaps involving depression/dissociation in the caregiver, emotional disconnection due to what some have called transgenerational transmission of trauma, similar to my variation on a concept by French analyst, Dolto: children walk on the perimeter of their parents’ nightmares, and point to it with their bodies). However, it is not just a matter of creating connection, for the latter often stirs up annihilation anxiety and self loss, resulting in the simultaneous overactivation of the seeking and withdrawal systems driven by the panic-separation system.
Paradoxically, connection can activate panic-fear of separation/abandonment. The therapeutic partners need to steer safe passage between allowing for the therapeutic symbiosis without exploiting it or defending against this deep form of emotional closeness. Understanding of these processes would lead to a reorganization of our systems of treatment, particularly for those patients unfortunate enough to find themselves in the state hospital system of care which often places minimal importance on continuity of care, the underlying psychodynamics and meaning of symptoms, secure attachments, and the development of self agency WITHIN the context of a secure attachment relationship (as opposed to only the psychoeducational transmission of information on psychotic symptoms, relapse prevention etc-as important as these attempts are, they need to be done within the context of a trusting and reliable relationship which, from my experience working in the state hospital system is rare and as Fonagy at our ISPS conference in London in 1997 emphasized, it is in individual psychotherapy that the chances for forming secure relationships, and therefore better affect regulation through interpersonal mediation of containing secondary representations, is maximized).
An important goal for ISPS would be to study ways as to how, practically, individual (as well as group and therapeutic milieu approaches) psychotherapy could be provided to those persons who have been denied access to this humane intervention. To counterbalance my idealization of psychotherapy with more disturbed patients, I would like to quote from Lawrence Freidman’s (1988) The Anatomy of Psychotherapy: “Therapists function in a sea of trouble and they talk as though they don’t. Respect and attention abound, to be sure, but the identifying truth about psychotherapy is that it is an uncivil, threatening [for both partners], even brutal struggle...” This brutal aspect was very clear to me in a session this weekend with a person feeling very injured by me and on the verge of quitting. She was expressing a great deal of hostility and hatred. Thanks to a passing comment of a colleague on the previous day, I was able to see my negative projections into her and to gain contact with and appreciate the positive aspects of her selfhood (similar to Benedetti’s therapeutic positivization, which the patient often resists, which is the creative variant of a negative projective identification). And as my good friend and colleague, James Ogilvie, pointed out, the patient was acting as therapist to her therapist (Searles). To only focus on her negative projections and accusations would be to lose contact with her attempts at creating a interpersonally safe relationship for both, and to unconsciously repair her internal damaged objects (see Henri Rey’s “That Which Patients Bring to Analysis” in Universals of Psychoanalysis in the Treatment of Psychotic and Borderline States-1994) in order to move on with living her life.
Amygdala & Paranoia
Human amygdala involvement is observed in a constellation of anxiety, as well as paranoid disorders. Individuals with paranoid delusions demonstrate increased amygdala and mesotemporal activation and reduced frontal activation (‘hypofrontality’) in response to threatening and neutral stimuli (Aggelton 1993; Epstein et al 1999; Isenberg et al 1999). It is noteworthy that activation of neuronal cells in the limbic system lead to a ‘silencing’ of prefrontal cellular activity (a neural basis for the role of anxiety in hypofrontality). This fits with Luc Ciompi’s (and the viewpoint of many others in ISPS including my own) theory of schizophrenia as being primarily an affective disorder (see his Affect-Logic theory of schizophrenia). I would say it is an affectively based psychobiological identity/self disorder.
Post-Kleinian Theory
For those interested in learning more about the Post-Kleinian theory (one of many) of therapeutic action and psychic change, I highly recommend “In Pursuit of Psychic Change: The Betty Joseph Workshop” edited by Edith Hargreaves & Arturo Varchevker in 2004 for Brunner- Routledge. I will quote some cogent material by Ignes Sodre from the book on this topic: “As is well known, Betty Joseph’s most original contribution to psychoanalytic technique is the particular emphasis on close attention tothe minute detail of the relationship [as Mies van der Rohe, the architect, pointed out, God is in the details] taking place in the here and now of the session-she is the master of particularity and specificity...psychic change...can best be achieved through the investigation of the minute changes in the patient’s unconscious behavior in relation to the analyst, especially following an interpretation; for she believes...that the response to the analyst’s activity - the analyst’s move towards the patient, and attempt to offer her own observation of his state of mind to him [what Fonagy and others would call mentalization] - creates a shift which reflects the deep layers of the archaic object relationship that is alive in the patient at that precise moment [for a similar viewpoint but from a different theoretical perspective see Dan Stern’s new volume “The Present moment in psychotherapy and Everyday Life” published in 2004 by W.W. Norton]. So it is not the transference in general, to be found in the material at large which is the focus of attention and descriptive comment, but the transformations in the movements ( towards, away, to the surface, to the depth, lighter, darker, more or less intense) of the subtle choreography between subject and object, in the patient’s mind, acted within the relationship with the analyst (since the analyst herself is an active participant in this relationship, her mind has of course also to be subjected to constant close scrutinizing) [failure to do the latter, I believe, is one significant drawback of a strictly cognitive-behavioral approach]. The central theoretical belief is that the archaic object relationship is to be found embedded in these exchanges, and that ultimately this has to be the main object of the interventions - which she aims to make as clear and simple as possible, avoiding cause and reconstruction until a much later time when there has been clear psychological development and when the transference is more solidly understood [Searles’ view was that transference interpretations are useless until a more solid therapeutic symbiosis is established] ...Although we talk...of archaic internal objects as if they were fixed structures, I believe it may be more useful to see them as dynamic structures whose qualities and functions are maintained by the way they are treated, and what is projected into them. This is essentially what makes psychoanalysis so difficult, often so deeply disturbing, and, yet, always such a fascinating endeavour; and, more importantly, on this fact (of the fluidity, or at least potential fluidity, of primitive object relationships) we base our hope of therapeutic efficacy” (pp36-37).
Brian Koehler
New York University
brian_koehler@psychoanalysis.net
