[From Bruce Abbott (2009.05.03.0655 EDT)]
BP: Bill Powers (2009.05.03.08523 MDT)] --
BA: Bruce Abbott (2009.05.03.0945 EDT)
BP: An excellent start on the discussion of PCT and disorders. Let me stir
the pot a little more.
The behavioral manifestations that lead to a diagnosis of schizophrenia
are diverse. These may include hallucinations (typically, hearing
BP: This is a problem for other people who worry about the reality of the
voices and what that implies, but how is it a problem for the person having
the hallucinations? That's what I would ask about. Is it all right with you
to be hearing these voices? If not, why not? If it's OK, we can move on to
something else. I've discussed hallucinations with people who had them, and
most of them were very bothered by having them. If I'd known about MOL then,
we might have got further, but I did explore the hallucinations with them,
asking things like whose voices they were, and so on. Maybe just my not
being upset by knowing the person heard voices was helpful. They didn't seem
so bothered afterward. The voices didn't necessarily stop, but people would
say, "Oh, there's Grandma Harriet again."
Many who experience these voices find them distressing, in that often what
is heard consists of condemnations and accusations. The person feels
harassed by them and would like them to go away.
BA: delusions (beliefs that are manifestly false to most of us),
possibly including delusions of grandeur and/or persecution (the
so-called paranoid delusions),
BP: Again, that is defining the problem that other people have with the
person who is deluded (that's a social problem).
Yes, of course. But I was describing behavioral manifestations of
schizophrenia, as viewed from the outside by others. Whether these
manifestations are a problem for the person is another question, and a quite
legitimate one to ask.
BA: disorganized speech (rambling discourse that may include
"neologisms" or made-up words), which in severe cases degenerates into
"word salad" that still follows grammatical rules but is meaningless to
BP: I wouldn't have the least idea what to do with that. Maybe ask the
person what the words or pseudo-sentences mean? Maybe I'd say "I didn't
understand any of that -- is that all right with you?" But I would try to
determine if there was something about this behavior that was a problem for
that person, not just for other people.
When I was a teenager our across-the-street neighbor had a 40-year-old son,
Harry, who had been diagnosed with schizophrenia, living with them. One
summer I contracted to mow the lawn for these neighbors and on one occasion,
as I was putting the lawn mower away, Harry came up to me and said "I see
you have a scratch." (I had scratched my arm on a rose bush.) "Our car has a
scratch; we went to Florida; I got a watch; . . . ." This rambling
monologue continued for ten minutes. Later I realized that the only thing
stitching the sentences together was a chain of associations. My scratch had
reminded him of the scratch on the car, which reminded him of the trip he
had taken to Florida in that car, which reminded him of the watch his
parents had bought for him in Florida, and so on. There seemed to be no
"executive" up there to organize his thoughts, just an associative chain.
Harry's parents told me that his problems began in high school. He had been
an excellent math student and gradually became obsessed with mathematics.
They believed that his disorder was caused by this obsession with math: put
simply, it had driven him crazy. (There's a lesson for you! Don't be too
studious!) More likely it was the other way around. I suspect that Harry
was aware that he was losing his ability to think rationally and stay
focused; that his obsession with mathematics may have been an attempt to
preserve control over his thought processes by focusing on an area he was
good at, one with structure.
BA: distractibility (difficulty maintaining attention), odd repetitive
behaviors, inappropriate emotional outbursts (e.g., suddenly screaming
at someone for no apparent reason), catatonia (remaining immobile in a
state of "waxy flexibility, often for periods lasting hours), apathy
and withdrawal from the social world, and an apparent inability to
experience positive emotions such as happiness, joy, or love.
BP: in each of these examples, I'd try to find out, if I could, if the state
in question bothered the person demonstrating it. If a person suddenly
screamed at me "for no apparent reason", I'd ask if there were any reasons
for that, not say it was "inappropriate." Or I'd just ask if the person is
feeling very angry, or ask what the person would like to happen just then.
"Inappropriate" is of course in the eye of the beholder, not the person
doing the screaming. But let's say, for the sake of argument, that the
person believed that you were giving him that certain "look" that indicates
that you are a member of the CIA and are spying on him. (He thinks that he
can "tell" these things just by looking; no other evidence is necessary.)
You know nothing of this; from your point of view this person has simply
started screaming epithets at you for no apparent reason. But from the
person's point of view, this behavior is quite justified and not at all
irrational. But then, you are not working for the CIA and you weren't even
looking at the guy. Unless of course you're Rick Marken.
BP: The whole theme I'm trying to get across here is the idea of trying to
find out what errors the person is trying to correct, or what difficulties
there are with correcting them. My own opinions of what is wrong with the
person are irrelevant from the PCT point of view. I can't reorganize the
other person (though plugging his brain into a wall socket might do some of
that, if not in a very organized way).
In my imaginary scenario, the person is trying to get you (and the CIA in
general) to stop spying on him. Screaming at you is one possible way to do
this. But it isn't working -- after you leave, there will be others. Now
that we know what the person has difficulty controlling, what now?
BA: I worked as a ward attendant at a large state mental hospital for a
short time while in college and had the opportunity to observe a number
of persons who had been diagnosed with schizophrenia. The dominant
impression I had was that these were people like you and me. With most
of them, most of the time, you could have an ordinary conversation
(anti-psychotic medications were just then coming into use). But I
don't mean to convey that there was nothing wrong with them.
Schizophrenia is no illusion. It is a highly debilitating disorder --
although of course there are degrees, from mild to severe.
BP: Yes. But "debilitating" is in the eye of the beholder -- it depends on
what someone thinks the person ought to be able to do. If that someone is
the person in question, fine, but if it's someone else, nobody is going to
reorganize in any fundamental way just to make someone else feel better.
Excellent point. Many of those diagnosed with schizophrenia seem to believe
that there's nothing wrong with them; it's all those other people who are
wrong. But they're not happy, either, and they know it.
BP: And somehow I doubt that the same thing was wrong with every one of
those "schizophrenics." That's just a category, isn't it?
Yes, it's just a category. As I noted, the "symptoms" are varied and tend
to change over time. There's likely to be a wide range of causal factors
BP: In high school I sometimes played boogie woogie piano in the mental
wards of the VA hospital in Hines, Illinois (my mother was a Gray Lady
there). I had the same impression that you got: I wasn't very different from
the guys locked up there. Perhaps I was even a bit less different from them
than you were. Even they, however, told me they were different (but that I
didn't need to worry about it, which I learned not to do). But the question
I had and still have comes down to this: what did THEY think their problem
was, and was anyone trying to help them with that?
One problem they have is that they've been diagnosed with schizophrenia,
with all the negative connotations the diagnosis entails. By the way, I've
been using the rather awkward phrase "behavioral manifestations of
schizophrenia" partly to avoid calling those who have been diagnosed with
schizophrenia "schizophrenics" (which I think is depersonalizing) and to
emphasize that these "symptoms" are (or are inferred from) observable
behaviors. You can observe catatonia and can infer disordered thought from
what the person tells you.
BA: From the PCT perspective, it may be easier to state what isn't
wrong than what is. A person diagnosed as schizophrenic does not appear
to have any problems with lower-level control systems, unless
dyskinesias develop as a side-effect of medication. (Catatonia may be
an exception, but see below.) The person has normal use of skeletal
musculature. He or she can walk, talk, manipulate objects, and so on.
Ordinary perception is intact: the person doesn't walk into walls or
step off a sheer drop. Memory seems to function normally.
BP: Yes, it's clearly a higher-level problem, though in many cases I think
it's a problem with how to deal with lower-level problems like
hallucinations. There isn't anything abnormal about hearing voices that
aren't really there; sometimes that's how I remember parts of a
conversation. It's just the imagination connection. The real problems arise
in the higher-order interpretations of what the voices say, or of the fact
that they are experienced.
BA: On the other hand, the person may be perceiving things that aren't
there, such as a scolding inner voice. Is this the imagination
connection run amuck?
BP: Why "run amuck?" That's how it's supposed to work. Maybe the problem is
with a higher-order system that keeps the voices turned on all the time, for
some reason we might explore.
I can "hear" my own internal speech, but I'm not prone to believing that
what I'm "hearing" is being beamed into my head by space aliens or is the
voice of God. "Amuck" in the sense that the person seems to have lost the
ability to make that distinction.
It just occurred to me that these alien inner voices might reflect some
autonomous process going on in the brain, similar to "autonomous arm
syndrome." In the latter case, a person's arm seems to have a mind of its
own -- moving about, grabbing onto things, and so on against the will of the
person. It can result when certain parts of the brain are isolated from the
rest by disease or damage. It would be interesting to see what would show up
in a brain scan for brain activity while the person is hearing "the voice"
as opposed to when hearing what he attributes as his own inner voice.
The voice seems real enough to the person and entering the head from
some external source. The ability to "reality check" is compromised:
the person may hold fast to beliefs that are contrary to fact, logic,
or common sense. The person may have difficulty controlling attention.
In the severe case of "word salad" an entire monologue may consist of
sentences whose only connections are associative.
BP: That's what I would focus on: do the voices sound real, and does the
person think they are really real? In the worst cases you describe,
naturally we have to suspect some kind of organic problem that can't be
dealt with psychologically, but I'd never assume that to start with. You and
I have debugged enough programs to know that a wise analyst never starts out
by blaming the hardware.
My experience was that most of those diagnosed with schizophrenia had fairly
rational periods when one could explore these issues, especially if the more
florid symptoms are being well-controlled by antipsychotic medication.
During more severe episodes, it might be more difficult to conduct such a