Monthly Archives: November 2015

From Fiction to “FACT” – MPD, Recovered Memory and Now Trauma Causing Schizophrenia

By Dr David Laing Dawson

We are worried that our young people playing first person shooter games will mistake these fictions and entertainments for reality. That they will drive on city roads the way they drive in Grand Theft Auto. That they will believe the pedophile posing as a teenager on Facebook is someone they could trust, who understands them so well. That they will believe incessant texting between ten BFF’s constitutes productive and healthy socialization.

Well, it does happen. And we need to monitor those boundaries closely.

But there may be another, more subtle consequence of ubiquitous, accessible, omnipresent entertainment.

I suppose throughout history our popular conceptions of reality, of health, of medicine, the way things work, were often drawn from the fictions of folk tales, ancient texts, stories told around the campfire. But it is only within very recent history that we have had access to, and been inundated with, entertaining fictions twenty-four hours a day. What influence does this have on our folk philosophies, our sense of how the world works? And how much does this creep into official and professional conceptualizations?

Even before Dr. Jekyll and Mr. Hyde, writers of fiction used the literary conceit of creating two characters embodied in one to explore psychological inner conflict. I think the first film version of this story was made in 1931. And since then numerous films have been made using this literary technique. The most famous being The Three Faces of Eve, based on a book that was initially presented as a case study, but later, (and admitted by the author) found to be the use of the literary device of embodying the conflicted mental states of a troubled woman in separate invented characters. And from this arose Multiple Personality Disorder. It moved from fiction to reality in popular culture, then professional culture, and spawned a counseling industry. It is hard to resist, that moment when the voice of the 30 year-old white woman changes to that of a black man from New Orleans and tells you a new story of origin. Very dramatic.

Of course it was all fiction, the product of fertile imagination and our hunger for the exotic – in each case the product of a collaboration between a naïve therapist and a troubled but impressionable patient.

MPP still shows up now and again as a device to satisfy the plot of a television movie of the week, but has otherwise, I hope, disappeared from serious psychological literature.

But no sooner did multiple personality disorder remove itself to the museum of human folly, than we were inundated with stories of recovered memory, of children remembering scenes of rape and torture, satanic ritual and sacrifice, events that they had forgotten until prompted by a counselor. It didn’t seem to matter to therapists recounting these stories that a.) In the United States the FBI knew of no cases of satanic sacrifice ever happening (except in movies and TV), and that b.) Many of the stories included outrageous details involving animals from other continents, or time travel, or aliens, and c.) Memory just doesn’t work that way.

Lawsuits abound from the Recovered Memory Therapy activities. Some launched by the alleged victim of the alleged perpetrators, some by the alleged perpetrator, and many filed later by the alleged victim against the therapist who “planted these memories.”

(Sexual abuse does occur all too frequently, and counselors and therapists should create, in their relationships with their clients, an atmosphere in which a bona fide memory of this can be shared – but to seek this in the childhood of someone who does not remember it ever happening, through hypnosis and persistent suggestion, is wrong, and a serious misunderstanding of memory.)

Much of this has been an embarrassing chapter in our professions. Some years ago a local psychiatrist, testifying in a Satanic Ritual case, was quoted as saying, “Children don’t lie.”

Perhaps she meant that children often blurt out a truth that an adult wouldn’t, such as “You’re fat.” or “Your breath smells.” But of course children lie, and usually in a childlike fashion, just as teens lie in a much sneakier fashion, and adults lie in a sophisticated fashion. And children want to please the adult questioning them, and they sense quickly the kinds of stories that please that adult.

And then we have “flashbacks”. Okay. A true psychological phenomenon is an intrusive memory or intrusive image, a memory or image that intrudes unbidden in one’s consciousness, most commonly when alone and idle, but also, and disturbingly, at other times. This is a hallmark, of course, of PTSD.

But flashback is a word drawn from cinema. It is a clumsy technique in literature, but very useful and dramatic in film. And in film it is used as a dramatic means of explaining, of showing, the past events that led to this current event. It is also used in film to visually depict an inner state or a memory. Sometimes it is shown shadowed and vague, probably a fairly accurate visual representation of a thought. But sometimes it is shown in full colour narrative with intact dialogue. And good filmmakers handle the flashback with parsimony to ensure suspense.

But film, theater, drama, follow rules that don’t apply to real life. The story arc. The character arc. The tying up of loose ends. The reveal. The always understandable, easily followed cause and effect. The satisfying ending. And for an ending to be satisfying in cinema we need to understand cause, the forces driving the narrative, at least before we fade to black. And these causes need to be things that provoke outrage, anger in the viewer, along with a fantasy that had we been there we could have fixed or prevented this. Even when the true villain is a natural disaster the filmmakers symbolize the cause in a single despicable human character. This is theater and film. I watched another last night. The main character appeared to be suffering from ASD and  some OCD. He was also seeing and conversing with a ghost, and he believed he was the Son of God. All of these afflictions disappeared when the ghost led him to flashbacks that allowed him to grieve the loss of his father. Ahhhh. But it was entertaining with William H. Macy as the therapist, and, of course, as film must be, believable within the rules of its own fictional universe.

It is what film must do. Delusions, psychotic symptoms, hallucinations must be either resolved by some denouement, some revelation (often shown by flashback), or, in a twist of plot, found to be true. The paranoid delusional conspiracy theorist is actually onto something, and the CIA is unhappy about this.

Other marvelous literary/cinematic devices include the appearance of a ghost, often delivering a message or a guidance, and the hearing of voices, whether from someone on screen or off screen. “Luke, Luke, beware the dark side.” Again, offering either guidance or warnings.

Now in reality, visual hallucinations are usually a sign of brain impairment, injury, toxicity, dementia. Although mistaking a shadow for a person or a ghost momentarily is rather common late at night after watching a horror movie.

And voices. A previous blog described the many conditions within which this phenomenon occurs, and to some extent the nature and kind of hallucination in each case. But cinema is not bound by medical realities.

I offer this history of literary devices and cinematic techniques finding their way into popular or folk wisdom, and then professional culture (multiple personality disorder, recovered memory as examples) as a way of asking if it is happening again.

Might the current phenomenon of psychologists pursuing “trauma” as an underlying cause of psychosis, of trusting “recovered” memory, of trusting those fully formed flashbacks of which their clients speak, of seeking prophetic meaning in “voices”, and the whole Hearing Voices Movement for that matter – might all this be another example of the fictional devices of film and television drama creeping into our folk wisdom and then into the received wisdom of some professionals?

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Results of Family Survey – Onset of Schizophrenia

By Dr. David Laing Dawson and Dr. Giampiero Bartolucci

Background

Our ability to see, hear, read, and correctly interpret pre-textual and contextual* information is a brain function independent of I.Q. This ability in the normal population continues to improve (from birth) long past the age that other skills fall off.

This ability allows us to hypothesize the intention and motivation of other people, that is, to be aware of (up to a point of course) the workings of the others mind. That includes the perception of others as having minds, feelings, intentions, motivations, roles, responsibilities, needs.

This allows us to experience empathy, to grasp from this information both what is likely to happen next and what is expected of us in any given situation.
It allows us to formulate an internal social map of which we are a part. It allows us to develop a rational appraisal of cause and effect in our social world. It allows adaptability. New contextual information can be used to modify our internal map.

This ability begins to develop before language. From the moment the infant smiles at mother and mother smiles back.

The brain is an analyzing and organizing machine. It will organize information to formulate cause and effect and predictability. If the information is contradictory or missing it will seek further information. Anxiety/arousal will spur this seeking. Anxiety will continue until the brain is satisfied with its cause/effect organizational answers.

One part of this ability allows us to perceive objects according to their function in the human world. We perceive a chair turned upside down as still a chair because we know the object’s function. A three year-old child with normal pre-textual/contextual ability will approach a toy car and push it along the floor. An autistic child may pick up the car and spin it’s wheels with his fingers. This action may be fascinating to him. For the other child, the human function of a car and car-toy is more important. This child with good pre-textual/contextual information processing skills may race the car, turn corners with the car, stuff a small model in the car, and crash it into another toy.

It is this contextual information processing ability that allows affiliation: Being one of a pair or group and then operating within that group in ways acceptable to that group.

As textual language develops it can complement non-textual skills. But non-textual skills are required to modify and modulate language in social context. The child without, or less adept at pre-textual communication skills, may develop impressive textual skills that lack contextual nuances. His words and sentences are heard as overly formal, and often devoid of cadence, and/or contain unusual cadence and prosody.

As textual skills develop without pre-textual skills and as these are used to understand and interpret the social world around us, and formulate an internal map of cause and effect and expectations, that map will become inflexible, black and white, as stark as the usual text message.

In our average social world, for example, the word “yes” can be spoken in many ways, and guided by many facial and body language cues, to mean anything from a clear affirmative to a hesitant “Maybe” and even, really, “No.” But in text, “yes” is “yes”.

It is possible to reduce the need for pre-textual, contextual information processing skills by social isolation. And, uniquely today, we can retreat to a virtual social world where meaning and organization can be found in text alone. The player of a computer game, even one with multiple players, enters that world as an expressionless alias, an avatar, and engages through text and basic actions. Strategizing may be involved but the actions range simply from aggressive to evasive. If an affiliation is developed it is developed through text and mission.

While isolation protects one from the anxiety of being part of an incomprehensible (unpredictable) social world, it leaves the brain with little to work with as it develops its maps of cause and effect, social organization, expectations of behaviour, and ways of understanding ourselves within this social world.

But for our human brains, this is an imperative. It must do this.

We have long hypothesized that some non-affective psychotic illnesses (setting aside those psychotic illnesses that can be clearly traced to seriously abnormal mood states – e.g.. feelings of exaltation, elation, power, invulnerability, extreme energy leading to a conclusion (an assessment of affiliation) that one must be a prophet, a messenger of God, or God himself) – that non-affective psychotic illnesses are the result of the brain developing a system of cause and effect, an internal map, from whole cloth as it were, because it is experiencing an inability or decay in the ability to process contextual information. The intervening state is anxiety, followed by compensatory behaviours. When these compensatory mechanisms fail, psychosis develops. **

These are the psychotic illnesses that often receive the diagnosis of schizophrenia.

The Survey

Our survey used the internet to reach the family members of people who have developed psychotic illness and received the diagnosis of schizophrenia. 240 completed the survey though it required reading a long introduction and the choices were complicated.

The questions were designed to separate different pathways to psychotic illness, with five choices. Participants could choose one pathway or more than one if a combination was a better fit.

Choice one (1) implied a deficit in pre-textual/contextual information processing from infancy or childhood, with devolution to psychotic illness later.
36 chose this category alone, and 58 alone and in combination with others.

Choice two (2) implied a normal development of pre-textual/contextual information processing through childhood followed by a deterioration of this skill in adolescence.
43 chose this category alone, and 80 alone and in combination with others.

Choice three (3) implied a normal development of pre-textual/contextual information processing through childhood followed by over-interpretation of bits of information, finding meaning and linkages where none exist, or unable to filter out random and coincidental information.
16 chose this category alone, and 33 alone and in combination with others.

Choice four (4) implied a primary problem with emotional regulation: The emotional over reaction to interpersonal events followed by mistaken interpretations of them.
14 chose this category alone, and 56 alone and in combination with others.

Choice five (5) tried to separate those clinical situations in which hallucinations, hearing voices, might have been the first symptom of a developing psychotic illness.
22 chose this category alone, and 58 alone and in combination with others. Though in the comment section many stated that the confession to hearing voices came late in the illness and they then surmised it was an early symptom.

Those who did not choose a category and commented described unusual situations and/or late onset psychosis. (Onset age 40 for example, or many years of drug abuse)

Interpretation and conclusions:

A. Family members are eager to find answers and willing to spend time helping this pursuit.
B. The internet provides a very efficient way of collecting this kind of data and could be used for much wider studies.
C. The largest group of individuals diagnosed with schizophrenia followed a pattern of apparent social success in childhood, followed by developing social failure in adolescence, isolation and retreat, compensatory and seeking behaviours, and then delusions and disorganization.
D. The second largest group appears to have had pre-textual and contextual information processing problems throughout childhood, leading to various degrees of social failure. In adolescence this increases and devolves into psychotic illness.

Less common pathways to psychosis and the diagnosis of schizophrenia may not involve a failure to develop, or a loss of, contextual information processing skills, but rather begin with (3.) an affect regulation disturbance.
(4.) an uninhibited or excessive interpretive mechanism (search for meaning)
(5.) abnormal auditory, visual or tactile experiences.

Though usually 3 to 5 were observed in combinations with 1 or 2.

The diagnosis of schizophrenia is applied to psychotic illnesses that may have different causation and pathways. Our historical attempts to delineate these have relied, not on distinct pathways, but differences in the later psychotic state or outcome.

The results of this survey reinforce the need to consider the diagnosis of schizophrenia as encompassing several different illnesses. Each may have a different set of genetic and epigenetic etiological factors. If we can further delineate these pathways it will help us with early detection, screening tools, focused treatment, perhaps prevention.

Two pathways stood out:
Failure to develop pre-textual and contextual information processing skills in childhood, devolving into psychosis later.
A slippage or decay in this ability in adolescence. (Adolescence is the time of final development of the brain through a process of increasing and reinforcing neural pathways that allow adult function while pruning networks no longer needed.)
­­——————–
*Several words are commonly used to categorize the information being exchanged in human communication beyond, or other than, actual text (words): non-verbal, contextual information, pre-textual communication, pragmatics. The words used reflect the field of enquiry: e.g. ‘pre-textual’ in primate studies refers to forms of communication that precede the development of language (words). The linguists are fond of the word ‘pragmatics’.
We have chosen to use the words ‘pre-textual’ and ‘contextual’. Pre-textual to emphasize how this non-verbal communication precedes text and is primal. Contextual to refer to everything beyond actual text from cadence of text, choice of specific words, to facial expression, eye and pupil movements, to surroundings, situation, role, and history.

** Schizophrenia in Focus, Human Sciences Press, New York, 1983
David Dawson, Heather Munroe Blum, Giampiero Bartolucci

Visiting Day

Shot in the Head A Sister’s Memoir, A Brother’s Struggle is published by Bridgeross Communications (Marvin Ross) and is available on Amazon, etc and in various e-book versions

word from the trenches

Paul says Grandma died in his arms.

He felt her spirit leave as he carried her up the stairs.

The girls were wailing where she had collapsed,

Mother was calling for an ambulance.

Dad hovered on a lower step,

waving his hands like a symphony conductor.

“Gently now, she’s not a sack of potatoes!”

But Paul says Grandma was already gone.

“I know because her spirit spoke

to me as it slipped by.”

He confided this news to me

twenty-five years after the fact,

in the visitors’ lounge of Rockland Psychiatric Hospital

just moments after demonstrating

(palms pressed against his brow,

eyes and mouth a Halloween grimace)

how a famous neurosurgeon had squeezed

little, tiny, baby Paul right out of the top of his head.

“You won’t have to worry about

that brat anymore!” he promised.

“What did Grandma say?” I asked.

And he just looked at me

with those…

View original post 249 more words

The Best Treatment for Psychotic Illness is no Secret.

By Dr David Laing Dawson

Nor does it require argument and more research comparing one component to another. This is it:

  • Early intervention, thorough assessment.
  • Treatment with medication by a knowledgeable physician/psychiatrist.
  • A good working relationship between psychiatrist and patient and his or her family.
  • Adequate housing with support.
  • A supportive family.
  • Ongoing education for patient and family about illness and treatment.
  • A wise, grounded counselor/therapist/support worker.
  • Easy access and rapid response support team for crises and emergencies.
  • Healthy diet and exercise.
  • Good general medical care.
  • Membership, belonging to a group or organization of some kind.
  • Daily routine.
  • An activity that provides some sense of worth and value.

When the support systems are in place, and a good working relationship has developed between the psychiatrist and patient and family, pharmacological treatment can be (safely) titrated down (or up) to the lowest effective maintenance dosages. Occasionally, with close monitoring over a long period of time, this can mean trials of no medication.

In the real world there are dozens of reasons this ideal is not often achieved, or only partially achieved. And some of those reasons include the interminable nonsense spouted by the Mad in America Group, inter-professional rivalries for prestige and money, illness deniers, would-be gurus, and politicians and planners listening to this nonsense.

Madness and Meaning

By Dr David Laing Dawson

As a young physician entering the world of the asylum, the mental hospital, the world of insanity, like many others before and since, I was fascinated by the prospect of finding meaning within madness, understanding behaviours that appeared, at first blush, inexplicable, understanding the de-contextualized speech patterns of many patients, understanding their delusions and voices.

This was the era of Timothy Leary, of a wish on the part of some to find a chemical path to enlightenment, the era of R.D. Laing seeking parental and family causes of insanity, of Thomas Szasz telling us that mental illness is a myth, the time of Foucault telling us that our society causes madness, and Alan Watts telling us that, really, madness was just an alternate flight path.

And, I must admit, madness, delusions, hallucinations, voices, fractured speech patterns, catatonia, mania, and even stuporous depression, contain rich and fertile ground for an artistic and literary imagination, and always fodder for philosophical questions about reality, meaning, semiotics, the nature of a human being, the manner in which we define deviance.

In our therapeutic communities of the day we talked and talked, in small groups and large groups. We listened to delusional ranting, to the reporting of voices emanating from the back of the head or from the dead, from an alien spacecraft, from God, and from the devil. I have spoken with several Queens, a few Christs, a man who tried to kill a president, a man harbouring evil beings inside his body, a man with the gift of teleportation, with many who believed the radio and television and popular songs were sending them personal messages, to many who believed they were being controlled by radar, radio waves, microchips, to men who wanted to cut off their genitals, to others who wanted to gouge out their eyes, to a few who wanted to kill someone who was controlling them from afar.

Of course we can find meaning in all of this, in each and every delusion, in each and every ephemeral message. And the meanings can be deep, intellectual, fanciful, alluding to Greek Mythology, Shakespeare, intrusive government programs, Kafka. They can be Freudian, Jungian, Adlerian, Foucaultian. They can even be new age and theosophic.

Or the meaning can be found more simply in those basic parameters of our social world and our sense of self: power, control, influence, intimacy, sexuality, responsibility, worth, love, hate, guilt, fear.

But does this help?

If it helps us empathize, yes. If it helps us form a relationship, develop trust, rapport, acceptance, yes. If it helps us accept these sufferers as fellow human beings, yes.

But might it not be more important to treat that young man who wants to gouge out his eye, before he actually does it, rather than worry about Oedipus Rex?

A Psychiatrist Discusses Hearing Voices

By Dr David Laing Dawson

In the winter of 1968 I finished a 24-hour shift in the emergency department of a major Toronto Hospital, changed quickly, and walked out into the still dark morning to catch the trolley on Bathurst St. I heard my name called, over and over. I looked for the source. It seemed to come from the electrical wires strung high above the street. I got on the uptown trolley. I looked at my fellow passengers. They were each oblivious, each locked in their own private early morning thoughts within their heavy winter coats.

Sleep deprivation and stress.

I don’t remember the particular stress of that 7 AM to 7 AM shift, but in 24 hours it must have included some bleeding, screaming, and dying, some vomit and rage and insanity, some crying and bewilderment, some failure.

I have no doubt that it is a simple slippage in our brains that can take our thoughts, our inner dialogue, our inner fears and our self-reassurance, and have us hear them, hear them as if either coming from outside our heads, or from an ‘other’ in our heads. In fact, when you think about it, it seems quite remarkable that usually our brains can make a clear distinction between the inner and the outer. So I am not surprised the boundary can be so easily broken in times of high anxiety, fear, stress, sleep-deprivation, psychosis, brain impairment, and trauma.

I am also not surprised that these voices often carry one of two kinds of meaning: accusations, fears, nasty directives or calming, reassuring, comforting messages. The phenomena that might be more difficult to understand are the hearing of conversations, undecipherable mutterings, even crowds shouting at one another. But then again, if our thoughts are often conflicted, unclear, inarticulate, there is no reason to assume thoughts that become voices would be otherwise.

In the many years since 1968 I have talked to hundreds of people who hear or have heard “voices”.

The most common of these is the hypnagogic experience, occurring in the moments between wakefulness and falling asleep, and the hypnopompic experience during the process of wakening.  I’m sure we have all experienced, at times, the overlapping of dream states and wakefulness, with sounds and images from from each world colliding. As a psychiatrist though, I usually hear about it from a parent or patient worried that it is a harbinger of something serious. It is not. Though this overlap can be increased by drugs that alter the rhythms of sleep, and by anxiety and stress and sleep deprivation.

Then we have the shy, anxious, overly-selfconscious teenagers who imagine, and then feel, and then think they hear their peers speak about them in the crowded hallways and cafeterias of school. For the boys it is usually an accusation of failure, of stupidity, of weakness, of failed or unwelcome sexuality. For the girls it can have more to do with dress, complexion, blemishes, size, being alien, as well as stupid, a loser. If it is the product of anxiety, social anxiety, in this age group, the teen usually, once away from the experience, understands he or she probably imagined it.

But it is often the reason they refuse to go to school, isolate themselves, become depressed. It is painful for them. And it is alleviated by good counsel and medication.

(Of course there are also instances of groups of teenagers actually systematically taunting and commenting on a schoolmate’s shortcomings)

The next most common cause of hallucinations may be brain impairment, from injury,  disease, toxic substances, withdrawal from alcohol, or dementia. And these experiences of imaginary people, imaginary events, fearful reactions, and conversations with visual and auditory hallucinations are scattered, disjointed, intermittent, chaotic, changeable. They also may overwhelm reality, replace it. And if the brain impairment can be treated they go away.

And then the psychotic illnesses: In the exalted state of mania with its feelings of power, of influence, of supreme importance (often accompanied by sleep deprivation), the thought that becomes a voice often belongs, as one might anticipate, to God. And the messages are prophetic and instructive. Usually instructions to share one’s new found wisdom. But sometimes they draw on the Old Testament and include fire, flood, pestilence and vengeful punishment.

Fortunately we now have medicines that quell acute mania in short order, and prevent, if taken regularly, relapses.

In the past it was not uncommon for a manic person to die of exhaustion, pneumonia, exposure, or to wreak some havoc, before coming back to earthbound reality.

And then we have a psychotic depression. Again if the boundary between thought and auditory experience is broken, the thought-voices align with the person’s mood. They are dark, hopeless, foreboding. They speak of death and disease. Usually the sufferer’s death and disease, but sometimes, with some men and women, the death of their family as well.

Undiagnosed and untreated a psychotic depression often leads to tragedy. Again, fortunately, our modern treatments, including ECT, are very effective.

And then we have  the schizophrenias. In my experience the hearing of voices is just one part of schizophrenia, a small part, though often very distressing to the sufferer. Many don’t admit to voices until years later. (For over a year it had remained a puzzle why one young man jumped off a school roof. Until he was well enough and he trusted me enough to tell me about the instructions he was receiving at the time.)

And the voices, the transformation of thoughts to an auditory experience, again follow the pattern of the sufferer’s feelings, ideas, distorted interpretations. They are often accusatory in nature, exacerbating guilt and self-loathing. They are sometimes instructive. That is, they might propose an action that will stop the pain and suffering of others. Such as jumping off a roof.

For most people with schizophrenia who do suffer auditory hallucinations the voices are tormenting. They would like them gone. A few get used to them, learn to ignore them. A very few, eventually, allow them to become a comforting background buzz within their otherwise socially isolated lives.

And an equally common symptom of schizophrenia is the reverse: the discomforting conviction that others in your proximity can hear every thought you have. Your thoughts are being broadcast as it were. (The treatment of schizophrenia is addressed in many other blogs on this site.)

Trauma. Abuse. It is again not really surprising that during acute trauma, during the experience of pain, fear and the threat of death and of absolute powerlessness to change this, our brains can take us elsewhere, that they have mechanisms at hand in these dire circumstances to transport us to kinder experiences in our imagination. For a child this may include being a different child with reassuring caregivers, better parents, a much more benevolent world. The more prolonged the abuse the more complex and real the imagined world may become. It could include multiple thought/voices that reassure and comfort. And others that threaten and punish.

The adult who survives this may carry with him or her both a hypersensitivity to threat, to the faces, noises, smells and symbols of threat, quick and exaggerated fear reactions, as well as an ability to call up, to return to, to run to, the other worlds of reassurance and comfort.

This is not schizophrenia. It is PTSD. We don’t have pills that fix this. Though we do have some that may improve sleep, alleviate some anxiety, and quell the most extreme reactions. And to focus on strength, to find a way to deny the memories, thoughts and voices that threaten, punish, and degrade, and to lean on the thoughts and voices that support, comfort and empower, is a good and courageous survival mechanism.

If the voice is comforting and supporting, and not interfering with one’s ability to live and survive and function in our tangible world, I would not want to try to quell it.