Schizophrenia As Evidence Disorder: A Clinical Hypothesis

2024 Author: Harry Day | [email protected]. Last modified: 2023-12-17 15:43

Schizophrenia is described by Eigen Bleuler (1908 - 1911) as a separate group of related mental disorders that lead to a steady and specific deterioration in thinking, deformation of emotions, and a weakening of volitional regulation of behavior.

The manifestations of schizophrenia are two series of clinical signs: productive psychotic (delusions, hallucinations, disorders of consciousness) and negative, deficient (disorders of thinking and self-regulation).

According to the concept of Eigen Bleuler (1911) / 1 /, the main manifestations of schizophrenia fit into the formula 4A + D:

1. Autism - detachment from reality and self-closure in the subjective world of experiences.

2. Associative loosening - deformation of logical mental operations up to the disruption of language constructs.

3. Ambivalence is a kind of "volitional paralysis" or the inability to differentiate and separate the actual experience from two or more alternative ones.

4. Affective flattening - deformation of emotional response.

5. Depersonalization - alienation from the experiences of one's own I or the splitting off of thinking and emotions from self-perception.

Eigen Bleuler's concept provides for a broad interpretation of schizophrenia - from severe psychotic to "mild" pseudo-neurological and clinically unexpressed latent forms. Accordingly, this concept suggested an overly extended diagnosis of schizophrenic disorders.

Since the 50s of the twentieth century, there has been a tendency towards a narrow interpretation of schizophrenia.

Kurt Schneider (1938 -1967) proposed to diagnose schizophrenia only in the presence of the so-called 1st rank symptoms:

a) verbal hallucinations (voices) of the commenting, dialogue type, as well as "sounding thoughts";

b) any worries about outside influences or "spoilage" in the body, thoughts, emotions, volitional manifestations;

c) delusional mood or delusional interpretation of real events or phenomena (Kurt Schneider, 1938) / 2 /.

After that, in the world psychiatric practice, in particular in the classifications of mental disorders and diseases (DSM, ICD), the interpretation of schizophrenia as a "specific" psychosis began to dominate.

On the basis of a narrow ("Schneider's") understanding of schizophrenia as psychosis, the main epidemiological and genealogical studies were carried out.

Conclusions from these studies can be summarized in two results:

1) the prevalence of schizophrenia in the general population is stable and ranges from 0.7% to 1.1%, that is, it is close to 1%;

2) the manifestations of schizophrenia "decompose" into the so-called spectrum of genetically related forms - from personality disorders of the schizoid type, borderline and schizotypal variants, to psychotic and so-called "malignant" ones.

Over the past decades, the study of schizophrenia has focused on neurobiological and genetic research.

Although specific markers have not yet been found, recent data indicate that genetic factors play an important role in the mechanisms of schizophrenic psychoses, and organic changes in these psychoses are observed in the cerebral cortex (A. Sekar et al., 2016) / 3 /.

The main problem of biological research is that on the basis of their results it is not possible to explain all the variety of the described clinical manifestations of schizophrenia. It is even more important to say that the genetic determination of the onset of schizophrenic symptoms does not explain the features of non-psychotic forms of the schizophrenic spectrum. Especially those forms that approach the so-called "soft" part of the spectrum, which is made up of persons with schizotypal (that is, doubtfully schizophrenic) and schizoid (non-schizophrenic) personality disorders.

This raises questions:

1) Genetic determination is the same for the manifestations of the entire spectrum of schizophrenia, or only for its manifestations of the psychotic segment?

2) Are there any specific clinical signs that are characteristic of all variants of the schizophrenic spectrum, including its non-psychotic manifestations and schizoid personalities?

3) If such common traits exist for the entire spectrum, then do they have a common genetic nature?

In other words, can a genetic "meaning" be found for a specific clinical underlying disorder characteristic of the entire schizophrenic spectrum - from its most severe forms to clinically healthy schizoid individuals?

The search for a central and even pathognomonic disorder in dementia praecox and schizophrenia was carried out even before E. Bleuler, and especially after it. Among them are the most famous such clinical hypotheses: mental discordance (confusion mentale F. Chaslin, réédité en 1999) / 4 /, primary deficit of mental activity and hypotension of consciousness (Berze J., 1914) / 5 /, illogical thinking disorder (K. Kleist, 1934) / 6 /, intrapsychic ataxia (E. Stranski. 1953/7 /, coenesthesia or disorder of the sense of integrity (G. Huber, 1986) / 8 /.

However, all the concepts mentioned relate to overt forms of schizophrenia with overt psychotic and negative symptoms. They also do not explain the peculiarities of thinking and behavior of persons belonging to the “soft” part of the schizophrenic spectrum, that is, persons without distinct negative manifestations, socially adapted and often highly functioning.

In this regard, one may think that attempts to search for such a clinical hypothesis that could interpret the biological, epidemiological and psychopathological features of schizophrenia have not lost their perspective.

The central hypothesis of our proposed concept of schizophrenia is formulated as follows:

1. Schizophrenia is a disease, the basic manifestation of which is a specific cognitive disorder, which is based on a violation of the interpretation of evidence.

2. Violation of the interpretation of evidence is a consequence of the "breakdown" of a special genetically determined mode of cognition of reality, in which the evidence is systematically questioned. It is proposed to define this mode as transcendental, since cognition in this mode can be based not only on the facts of sensory (empirical) experience, but also on hidden, latent meanings.

3. The transcendental mode of cognition may relate to the evolutionary biological need of a person to expand knowledge, questioning the evidence of the real. Not a single step beyond the limits of existing knowledge is impossible without a systematic doubt in the available evidence. Since cognition is the main factor in the development of culture, and culture (including technologies and their consequences for the environment), in turn, is an important factor in human evolution, the carriers of a specific transcendental mode may turn out to be a necessary part of the general human population, which bears "evolutionary responsibility" for transcendental ability to receive innovative knowledge.

4. Schizophrenia, therefore, is considered as a pathological disorder of the transcendental mode of cognition, in which a pathological interpretation of evidence is formed.

5. Interpretation of evidence is based on the ability of formal-logical operations with generally recognized facts of reality. This ability is formed at puberty. Therefore, the onset of schizophrenia should be attributed to this age (13-16 years), although the manifest symptoms may appear later (Kahlbaum K., 1878; Kraepelin E., 1916; Huber G., 1961-1987; A. Sekar et al., 2016).

6. The biological mechanisms of the onset of schizophrenia should be sought in the pathological processes of damage to neural systems that are responsible at puberty for the maturation of formal-logical thinking (judgment). As, for example, the hypothesis of Sekar et al. (2016) on pathological synaptic pruning in case of mutation of the C4A gene in the 6th chromosome.

Necessary explanations and comments on the hypothesis:

I. Arguments in favor of clinical manifestations.

There is no satisfactory definition of evidence. Most often, a simple description of it is used as a generally accepted concept, thought or impression, which is beyond doubt (from the standpoint of common sense).

The unsatisfactory nature of this definition requires an important clarification: the obvious is such, the perception of which is not subject to doubt from the standpoint of the currently generally accepted set of interpretations or understanding, which is called common sense.

Thus:

a) evidence is derived from a socially determined consensus based on common sense;

b) evidence expresses a set of paradigmatic ideas about reality at the present time (as, for example, the obviousness of the movement of the Sun around the Earth before Copernicus and vice versa - after him);

b) evidence is one of the main (and often indisputable) arguments in deciding the real state of affairs (entities), where the argument should be understood as evidence that is based on agreed by all parties.

Basic assumption: If schizophrenia is a pathological disorder of the transcendental mode of cognition, as a result of which a specific pathological interpretation of evidence is formed, then the following follows from this assumption:

1) this disorder deprives confidence and unambiguity (that is, forms distrust) according to the generally accepted set of interpretations and understanding of any perceived, that is, deprives the arguments of their obviousness in recognizing reality;

2) a person with such a disorder “does not fit” into the socially defined common sense, that is, he feels he does not belong to the existing social obvious;

3) as a result of the disorder, one's own interpretations and one's own understanding of the perceived reality and, accordingly, subjective argumentation, which does not bear the character of general consistency, are formed;

4) interpretations and understanding of reality lose the character of evidence and are based on subjective latent meanings;

5) a clear and constant distrust of the obvious, - in the absence of their own subjective argumentation (the person has not yet had time to develop such argumentation), - entails confusion, doubt and inability to manage oneself according to the requirements of reality, which is called a delusional mood;

6) if a disorder of obviousness leads to maximum distrust of reality and, as a result, disorders of perception are formed, then they are interpreted as subjectively obvious, and therefore are not corrected by reality;

7) situations that require maximum social adaptation to the generally accepted rules of reality, - and these are all critical situations that increase doubt and distrust of the obvious - anxiety, fear and confusion increase;

8) social adaptation in such crisis situations is most likely due to the development of two subjective, not corrected by reality, interpretive positions:

- or the social environment is hostile, does not accept, isolates or eliminates me for being different and not belonging to it;

- or it (social environment) gives me a special status;

9) named two interpretations, which in their unity are the basis of any delirium;

10) delirium, has both positions: and hostility from others, and a special status for others;

11) delirium blocks any arguments regarding obvious facts of reality and develops according to the mechanism of a vicious circle: from distrust to the obvious, due to delirium, to denial of the obvious.

II. "Metaphysical" arguments.

What mental disorder (without affecting the neurophysiological aspects of the problem, which are independent), can be responsible for the "disorder of obviousness"? The following brief excursion into the problem is required for an answer.

7. The recognition of the obvious in the perception and recognition of the real is based on the concepts and rules of formal reasoning. Reason, or reasoning, is responsible for the observance of these rules, while the mind is responsible for the knowledge of ideas and general principles.

8. A disorder of evidence, which is based on a violation of the generally accepted and undeniable interpretation of sensory experience of reality, is a violation of the rules of reasoning, but not imagination and the ability to have ideas. This could mean that in a specific schizophrenic disorder of evidence, the mind, as the ability to have imagination and give ideas, remains intact (not damaged).

9. The so-called transcendental mode of cognition, which is based on a systematic doubt in the obvious and is responsible for the “otherness” of interpretations of reality, can help in the search for non-obvious arguments in the system of the reality paradigm existing in a given culture. This modus may turn out to be an evolutionarily necessary mechanism for the development of cognition - in terms of the search for non-standard and new paradigmatic solutions.

10. Disorder of evidence in schizophrenia, however, consists in the formation of such "other" concepts that do not have socially agreed arguments and connotations, that is, do not correspond to existing ideas about reality.

11. If we consider schizophrenia as part of a single genetic spectrum, then this disease may turn out to be a necessary degenerative "payment" - an extreme version of the spectrum, in which the transitional forms are borderline schizophrenic states, and the other pole is a part of the population consisting of healthy individuals endowed with non-standard thinking …

12. That schizophrenia carries a certain biologically significant meaning is evidenced by the biological constancy of its incidence, in all cultures and in all social circumstances, is unchanged - about 1% of the population.

One may also think that the part of the general population, which is made up of individuals, are genetically endowed with non-standard reason, is also stable.