Schizophrenia

Lindsay Oades (Lindsay_Oades@uow.edu.au)
1 Dec 1998 08:47:14 +1100

Hi to all,
I have also enjoyed the recent discussion of schizophrenia and thought it was
time to enter the discussion. Comments regarding neuropsychology, corporate
construing, sociality and commonality are of particular interest. While I find
comments about vexenigmatic difficult to take seriously. I have the following
responses to various mails:

Regarding schizophrenia and development:
Tim Conner wrote:
>Even if, as I think we must, we concede that "schizophrenia" (or at
>least some "schizophrenias") has its roots in some dysfunction of the
>brain chemistry, we still need to take into account the effect on
>personality development of having such a condition. Not only the
>difficulty of construing and anticipating our own experiences, but the
>constant invalidation of our constructions by others.
and
>I think the constructivist/biological dichotomy is a rather unproductive
one (on both sides), hopefully one to be transcended someday.
I think that examining issues of the developing person are important in this
discussion. The view of schizophrenia as a neurodevelopmental disorder has
interesting implications for constructivist positions- If we take a position
such as egigenetic systems theory of development, the focus becomes how the
person's interaction with their environment (physical and social) relates to
their development. This is where I believe the dichotomy will be transcended.

On physical explanations and constructivism:
Tony Downing wrote:
>My main question asks why pcp has to be a game played with rules that say
>you are out if you mention the brain.
I agree that pcpers should examine this rule carefully. I think the comments on
looking at neuropsychology etc are very important. Constructivists could examine
the changes in construal over time of those diagnosed with schizophrenia,
dementia etc. A futher point, also relating to a previous post on depression,
just because something is seen as "physical" does not remove it from the domain
of constructivists- "physical" is an extremely useful construct or construct
pole- and just because we call it a construct does not, in my view, make it not
real.

On the conflation of "schizophrenia" and the "experience of schizophrenia and
all the things that come with it".
I agree with Bob Green who wrote:
>The more interesting question to me, is how can a constructivist approach
>assist people who receive the diagnosis of schizophrenia? What would such
>an approach look like/entail?
The focus on schizophrenia, differing names such as vexenigmatic etc, remain
pitched from an external vantage point rather than the intraspective vantage
point that I thought Kelly valued. My view is that the "empiricists" are
"cleaning up" the notion of schizophrenia, some arguing that factor analytical
studies to not demonstrate that the symptoms of schizophrenia cluster- arguing
that we should map the diagnostic system onto brain imaging etc. As a
constructivist I welcome this rather than abhore it- a biological explanation is
valid etc. Having experienced that the practices of psychiatry and science do
not always matched up I welcome the "razor empiricists" who are questioning the
construct of schizophrenia on empirical grounds.

I believe the constructivist understanding will complement such understandings
eg how do people with enlarged ventricles construe and interact with the world?
Which environments do they prefer to be in etc? In my view a constructivist
model should focus on the experience of those with "psychotic disorders". This
is necessarily a wider focus given that any "pathology" leads to dysfunction,
then to disability and wider handicap. Whatever we call these things, I still
find this group of people one of the most disadvantaged I have ever met. Their
experience includes all of these things not just the more interesting "voices"
and "delusions". Hence a constructivist model of the experience of those with
"psychotic disorders" in my view shold include:

-a process rather than structure focus
-responsibility of our construal of them
-identity issues
-developmental construction of experience relating to physical disturbances
-experiences and experiments with "symptoms" such as "delusions" and "voices"
-experiences of their environment ie hospitals, group homes etc
-experience of professional and non professional people
AND whatever the group of people also believe should be included- ie we should
ask them.

An example of constructivist understandings of delusions (from a paper I
presented in Brisbane earlier this year:

How do delusional beliefs relate to behaviour (McGinn, 1979)? This, in my view,
is a more important question in understanding delusions than using indices to
understand the structure of repertory grid results. In my view, we need to
examine the experiments the participants conduct rather than the results of the
experiments we conduct.
In terms of Kelly’s (1955/1970) analogy of person-as-scientist the idea of
testing out a delusion seems a most fertile area of investigation. While the
cognitive therapists are attempting to do so under the name of “collaborative
empiricism” it may be that the clients are doing it anyway. Wessely and
colleagues (1993) reviewed how prevalent actions relating to delusions are with
persons diagnosed with psychotic disorders. These authors found that actions
associated with abnormal beliefs are mcuh more common than has been previously
suggested. In personal construct terms, people diagnosed with delusions may be
experimenting with their beliefs more than has been reported.
Buchanan and colleagues (1993) examined the phenomenological correlates of
those delusions which are associated with action. Consistent with claims from
Kelly (1955/1991) in critiquing motivational concepts Buchanan et al (1993)
found no association between delusional phenomenology and acting on a delusion
when the participants behaviour was described by informants. However, when
action was described by the participants themselves, acting was associated with:
(a) being aware of evidence which supported the belief:
(b) having actively sought out such evidence;
(c) a tendency to reduce the conviction with which a belief was held when that
belief was challenged; and
(d) feeling sad, frightened or anxious as a consequence of the delusion.

These results are a long way from the myth that a delusion is unchangeable. The
vigialance for “bizarre” or aggressive behaviour appears to have lead to the
observational neglect of other less obvious inquiring behaviour. Future personal
construct research examining delusions would be well served to take heed of
Buchanan et al’s (1993) work on delusion related action and incorporate Kelly’s
later work in 1970 and 1977 that examines the process of experience.

Finally, a point on corporate constructs and schizophrenia:

Previous comments relating to schizophrenia and corporate construing are
interesting. Balnaves, Caputi and I have elaborated the original notion of
corporate construing, which is in press in the JCP- While doing this I thought a
lot about schizophrenia in terms of corporate construing- I agree, that
theoretically a focus on sociality and commonality is a fertile area. With a
smile I end this post by suggesting we replace vexenigmatic with sensus non
communis.

Regards
Lindsay Oades
Illawarra Institute for Mental Health
Wollongong
NSW Australia

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Subject: Can pcp and neuroscience jointly help schizophrenics?
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Date: Mon, 30 Nov 1998 13:04:07 +0000
Subject: Can pcp and neuroscience jointly help schizophrenics?
From: a.c.downing@newcastle.ac.uk (Tony Downing)
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Precedence: list

I'm grateful for the cordiality with which distinguished list members have
dissented from my recent dissenting message about the search for a purely
contructivist definition of schizophrenia. But I was dissenting, and
espousing a medical model, partly because I felt it wrong to define these
sufferers merely as people who interpret their world in ways that are
enigmatic and troublesome to (some) others. I wanted to advocate that pcp
should be prepared to work in tandem with neuropsychiatry, rather than
insist on being a radical alternative.

The constructivist definitions offered so far as replacements of
"schizophrenic" have been over-inclusive in that, as Jim Mancuso himself
implied (with his mention of strife in Jakarta), they would include
revolutionaries and all kinds of dissidents - and also many criminals. Is
that really desirable?
The rhetoric of antipsychiatry recalls memories of the abuse of the medical
model to stifle dissidents in the USSR and elsewhere, but that treachery
does not prove that the diagnosis of schizophrenia is normally an act of
repression, or that it is avoidable in democracies. A definition that
ignored all psychobiological findings and made vexenigmatic construing
sufficient grounds for detention in a psychiatric ward could play even more
readily into the hands of unscrupulous administrators.

My main question asks why pcp has to be a game played with rules that say
you are out if you mention the brain. There is such a thing as brain
damage, and whether it is localised or subtly diffuse, anatomical or
chemical, it usually has cognitive consequences. Pcp is a science of
cognitions and it must be possible to apply pcp even to construals made by
people with damaged brains. If it is made axiomatic that nothing from
outside pcp can feed into a pcp explanation, there is a risk of pcp failing
to to bring, to the understanding of psychosis, concepts and explanations
that only pcp can provide.

I believe that that now, almost 20 years since the Mancuso and Sarbin book
was written, so much has happened in general neuropsychology, in functional
brain imaging, and in specific neuroscience findings about schizophrenia,
that it is no longer tenable to expect that purely social-cognitive
explanations will suffice. I admit, however, that "Schizophrenia", with or
without inverted commas, is a complex story, not yet brought to an entirely
clear resolution. May I, therefore, explain my main point with a simpler
and less contentious example: Capgras syndrome, the belief that somebody
emotionally close to the patient has been replaced by an almost identical
copy, who, nevertheless, is not really that person.

As expounded, e.g., by A.W. Young et al. (1993), British J. Pychiatry, 162,
695-8, Capgras syndrome arises because there are separate brain mechanisms
for:

a) recognising persons from their features of face, voice, etc., and
b) linking this to relevant social information.

It seems that some people sustain damage to the brain, from a variety of
possible causes, (e.g., traumatic injury, tumours, possibly involvement
with an epileptic focus, etc.) and that this damage destroys the mechanism
for b) while leaving a) operational.

How does the patient construe the results? Often, it seems, they come up
with constructions such as "This woman, who appears to be my wife, is
really a zombie who is impersonating her". - Or that she is some other
kind of imposter, e.g., a criminal who is holding the real wife prisoner
and has cunnngly had plastic surgery so as to look like her. The result
has sometimes been that the apparent imposter is killed by the patient.

In at least some of the cases of the Capgras phenomenon there is no doubt
that the phenomen is a direct sequal to and consequence of brain damage.
Yet, obviously, the subsequent construing by the sufferer falls within the
domain of pcp. Not everyone with the relevant brain damage comes to the
same psychotic conclusions. Stone & Young (1997), Mind & Language
12:.327-364 propose that, in Capgras cases,

"an additional reasoning bias...
leads [the patient] to put greater weight on forming beliefs that
are observationally adequate rather than beliefs that are a
conservative extension of their existing stock."

Medical models are not always a demeaning attack on the individual. People
with epilepsy have every reason to be grateful to the medical approach,
which has saved them from being thought mad or demonic and has provided
drugs that often control the problem. Capgras syndrome quite obviously
provides an example where part of the story has to lie within neurology
and cognitive science; a damaged set of brain mechanisms then feeds bizarre
and inadequate information into a construing system that still tries to
make sense of what it receives and interprets this in the light of the rest
of the sufferer's construct system. there is no need for PCP to stand
aloof from contributing to the overall understanding of such issues.

Schizophrenia is to some extent still an open question, but in the light of
the Capgras phenomenon it seems to me to be unwise and unnecessaryto set up
definitions that exclude the possibility of an interface with neuroscience.

Having said that, it may indeed be instructive to see how far we can go in
defining schizophrenia in purely constructivist terms, but there is no need
to be hostile towards psychiatry and the medical model, or to confuse
schizophrenics with revolutionaries or criminals.

==========================================================================
Tony Downing, M.A., Ph.D.
Lecturer, Dept. of Psychology,
University of Newcastle upon Tyne, NE1 7RU,
UK.

email: A.C.Downing@Newcastle.ac.uk
Phone +44 (0)191 222 6184 Mobile: +44 (0) 468 427 481
Fax: +44 (0)191 222 5622
==========================================================================

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