הרצאה מתוך כנס IAAP אוגוסט2013
1. A few months ago, while working on this presentation, I was asked by a colleague to do a consultation, needed for forensic purposes. I will tell the story in short and later return to insights relevant to this talk. We had to deliver an expert opinion in the case of a young woman, aged 23 or 24, accused of having murdered her children. The story was terrible and had many echoes on the news. A young woman, from a Bedouin settlement in the south of the country waited for her husband to leave for work, then killed her three children. The story went even further. It seemed that she killed her baby child , then the brother who was aged one or two years, the eldest child aged two or three ran away crying that mother was beating him. He was met by good willing neighbors who calmed the child down and took him back to his mother, who killed him soon afterwards. I was sure I was going to meet a modern Medea,(slide) an evil sorceress motivated by who knows what dark motivations or at least a very disturbed non human monster. I was surprised to meet a young woman, clean, tidy, good looking, even coquette. She spoke good Hebrew (not very common with young Bedouin women). She came from a traditional family, went to school and graduated from high school (again, not very common). She hoped to become a nurse, maybe even a doctor. Actually she had good grades and had she applied, could have been considered, and had good chances to be accepted at one of our medical schools. But before she could understand it, at the age of 17, forced by her family and traditions, she found herself married to a cousin twenty years her senior. Soon afterwards she was pregnant, and then again and again. Her husband would leave for work early in the morning and return late in the evening, she was surrounded by lots of family members around expecting her to behave. Eventually she discovered that her husband was on the verge of taking a second wife. For years she had a "GENI", a kind of evil spirit talking to her, saying dirty words and pushing her to commit suicide or alternatively kill her husband or her children. She struggled with this voice but it became more and more present, more difficult to resist and one day she gave in, submitted to the GENI.
Was she sick? Was she schizophrenic? Was she supposed to be declared incompetent to stand trial? How, and if at all, are Jung's teachings helpful today, in spreading light on this human tragedy?
I will come back to these questions later in my talk.
2. Modern psychiatry began with the French Revolution and probably the first modern Psychiatrist was the French revolutionary physician August Pinel. (slide). Being a man in the spirit of his time, Pinel believed that the natural human condition is to be free, i.e. to be responsible for one's fate, to be able to make choices and to give meaning to one's life. Mad ones, the so called Lunatics, where those who due to a brain disease became alienated from their true nature. Due to their disease, he claimed, they became unable to decide on their future. According to Pinel, treating the alienated is not only curing their brain disease but helping them to become real human beings again, free people. With this ideology in mind the first modern psychiatric hospitals were founded.
In a way we are all Pinel's followers today, but only to some extent. We all believe that for someone to be mentally ill, there must be an underlying brain pathology, a certain inherited vulnerability, but we tend to disregard the other aspects of Pinel's insights.
3. Nowadays, when a person dear to us is afflicted with a serious disease, take cancer for example, we all encourage him to fight for his health, to be brave and go through painful treatments. A strong spirit, so we believe, will make the difference in many cases (unfortunately not always) between a terminal disease, and, more and more often, a serious but treatable condition. When a person dear to us is diagnosed with schizophrenia, most of us will have pity on him and on his relatives, we will look upon him as a victim to his brain pathology and at most, we will encourage him to comply with the doctors' advice, take medications etc'. We do not tend to encourage him to fight for his sanity.
On this aspect of schizophrenia it is so refreshing to recall Jung's teachings.
4. The 21st century research in the field of mental illness is characterized by enormous human efforts, the investment of enormous financial resources and breathtaking discoveries in areas such as human genetics, biochemistry, epidemiology and imaging. But does our widened understanding of brain functioning in health and in disease have sufficient impact on the destiny of the individual?
Before taking a short "Tour D'Horizon" of the current state of the art in the field of schizophrenia, let us remind ourselves once more the Jungian perspective.
5. The term schizophrenia was coined by Bleuler (slide) in 1908 in the Burgholzli hospital in Zurich. This term was a reaction to the "Dementia Praecox Syndrome" coined by his contemporary colleague Kraepelin, because, to quote Bleuler: "Today we include patients whom we would neither call 'demented' nor exclusively victims of deterioration early in life". The term he referred to was to a disease process characterized by destruction of the internal connections of the personality. A specific alteration of thinking, feeling and relation to the external world. In its course the personality loses its unity and the integration of different complexes is lacking. The course of the disease is at times chronic, at times marked by intermittent attacks which can stop or retrograde at any stage but does not permit a full "restitutio ad integrum". Bleuler discerned between fundamental symptoms in the areas of thinking, feeling and volition and secondary (compensatory?) symptoms as delusions and hallucinations.
6. During these years Bleuler worked with two young assistants, (slide) Jung and Binswanger. The latter was the founding father of existential analysis. Little wonder that working together in these formative years Jung and Binswanger influenced each other reciprocally, and the footprints of existentialist thinking is to be found in many of Jung's later works, particularly in the field of psychoses in which they worked together and further developed Bleuler's insights. For Jung the research and the understanding of the psychotic process is fundamental in the formation and the consolidation of Analytical Psychology. His papers on the field of schizophrenia are spread over all his productive years from 1907 till 1958. For Jung schizophrenia resulted from an "Abaissement du Niveau Mental" a lowering of the consciousness threshold caused by a peculiar "Faiblesse de la Volonte" (notions borrowed from Jannet). This weakening of willpower expresses itself in the way that a train of thoughts is not carried out to its logical conclusion, but is interrupted by strange contents that are insufficiently inhibited. As a result of this lowering of consciousness, complex-contents take over, and the predominance of ego consciousness is endangered. In contrast to neurotic conditions where complexes maintain a connection to the ego and the unity of the personality is maintained, in schizophrenia this connection can be completely lost. In schizophrenia the disconnected complexes will never reintegrate to the psychic totality or, if they can join together in remission, it will be like "a mirror broke into splinters" (slide).
7. Some important essentials regarding Jung's theory of schizophrenia: The lowering of level of consciousness reaches depths which are rarely reached in neurotic conditions while releasing, discharging and constellating deep, archetypal, collective materials which were inhibited and suppressed by the ego (slide). Naturally, these conditions remind us of dreaming, particularly of "big dreams" experienced on the cross roads of our existence. And indeed much similarity exists between psychosis and dreaming. It was Jung's original contribution to understand psychosis as a dream without sleep, or to put it in his words:"The dreamer is normally insane, or that insanity is a dream which has replaced consciousness". An example of a fragment from a dream and a fragment from the narrative of an acutely psychotic patient will show the similarity:
(slide)"…Then I am with S. and other unknown girls in some kind of a new house, modern, rich, and everything (the rooms ceiling etc.) is round. Between the rooms there are no doors, just glass and everything is transparent. Suddenly, I don't know what happens but I am alone. On the floor there are some triangular elaborate glass stones and I realize that they are not from this world. They are a little bit raised above the floor and activated by my movements. They see me. When I pass nearby they begin to rotate and then break to thousands of sharp glass splinters in the room. I must flee to another room. I realized the stones were evil and they aimed at killing me. I tried to run away and while running I activated more and room activating more and more glass stones. I felt exhausted moving from room to room and I felt I was going to die.
" …And every night D. (my husband), as if putting S. (my son) to bed, he kills him, and in the morning resurrects him".
Indeed, without knowing the context it will not be easy to guess what is what.
8. The schizophrenic complex has its peculiarities: Elements of a normal or neurotic complex are well-developed, even hypertrophied on account of their heightened energetic value. The Schizophrenic complex is characterized by a peculiar deterioration and disintegration, leaving the field of attention undisturbed. It looks as if in schizophrenia the complexes are destroying themselves by distorting their own contents. These complexes do not seem to draw energy from other mental processes, but devour their own energy, subsiding their own foundations and leaving the personality impoverished (or residual to put in modern words). Whereas the neurotic dissociation never loses its systematic character, schizophrenia shows a picture of unsystematic randomness in which continuity of meaning is often mutilated to the point of unintelligibility. (slide) The picture of the personality dissociation in schizophrenia is different from what is seen in other situations – the split off figures assume grotesque, persecutory or highly exaggerated names and characters. They do not cooperate with the ego-consciousness and often torment it. There is an apparent chaos of visions and voices and characters – overwhelming and strange. In schizophrenia the abaissement reaches a degree never heard of in neurosis – the very foundations of the personality are impaired. Normally inhibited contents of the unconscious are now allowed to invade consciousness.
9. This problem of the lowering of the level of consciousness and the individual attitude towards it is for me the main lesson to be taken from Jung' teaching:
(slide text) "Any abaissement , one that leads to neurosis means a weakening of the supreme control. A neurosis is a relative dissociation, a conflict between the ego and a resistant force based upon unconscious contents. Every neurotic fights for the supremacy of ego consciousness and for the subjugation of unconscious forces. A patient who allows himself to be swayed by the intrusion of strange contents from the unconscious, a patient who identifies with, and does not fight with, or is even fascinated by the morbid elements exposes himself to the suspicion of Schizophrenia (Being fascinated by regression!). The abaissement can reach an extreme degree where the ego loses all power."
10. A short illustration to emphasize this point: M., a young professional in his late thirties was referred to me a few months after the birth of his first born son. He had previously accompanied his wife in the maternity room. The delivery was complicated and evolved to a forceps procedure. He witnessed the gynecologist in his work with his hands inside his wife's body. Saw the blood. Little by little he felt more and more humiliated, he felt his wife being defiled. He could not be intimate with her anymore, he began to develop strange and hostile beliefs towards men gynecologists, he had murderous drives towards her doctor and began to walk around his house considering to attack him, he had recurring visions of his wife being torn to pieces in the hospital and more and more felt the urge to save society from what he perceived as pervert wicked gynecologists.
And yet he felt something went wrong, and whenever he felt overwhelmed by his visions and by his aggressive impulses he would bite himself, make himself bleed, so that the physical pains would weaken his phantasies and put him back in touch with reality. One day he was so tormented by inner destructive powers that he had to leave his office, he sat in a public garden biting and talking loudly to himself. As he drew attention, he was approached by a policeman who wanted to refer him to the nearest psychiatric emergency room. Luckily for him he managed to avoid being hospitalized.
We can imagine that had he been admitted to a hospital, he would have been put under heavy surveillance, heavily medicated, probably diagnosed, and in a serious danger of initiating the schizophrenic path.
I will come back to M. as to the first patient later on my talk.
11. Now to what schizophrenia is in the "era of the brain" and to the actual research endeavors.
As a definition, schizophrenia is a devastating psychiatric syndrome with a median lifetime morbid risk of 7.2 per 1000. The age of onset is typically in adolescence or early adulthood with onset after the fifth decade and in childhood both being rare. All cause mortality is elevated approximately 2.6-fold for patients with schizophrenia, with excess deaths mainly from suicide during the early phase of the disorder, and later from cardiovascular complications. Schizophrenia commonly has a chronic course, albeit with fluctuating patterns and cognitive disability. Its hallmark is psychosis, mainly characterized by positive symptoms, particularly hallucinations and delusions, frequently accompanied by negative (deficit) symptoms such as reduced emotions, speech and interest and by disorganization of speech and behavior.
(slide) The slide shows us the current DSM definition of the syndrome, showing how far we are today from the original Bleulerian definition. The original definition looked upon delusions and hallucinations as secondary, not necessary attributes of the disease, in contrast to the four fundamentals symptoms (Autism, Association, Ambivalence and Affect). For Jung the secondary symptoms are to be understood as having a psychogenic origin. As to the fundamental ones, he argued with himself whether they should be looked upon as the result of a specific inborn constitutional vulnerability or as being the result of (slide) "…An initial emotion which gives raise to metabolic alterations. These emotions seem to be accompanied by chemical processes that cause specific temporary or chronic disturbances or lesions". (letter to the chairman of a symposium on Chemical Concepts of Psychosis held at the second International Congress for Psychiatry in Zurich September 1-7,1957).
12. Is schizophrenia an inherited condition?
(slide) Bearing in mind familial risk factors, little wonder that the deciphering of the human genome yielded hopes to uncover the underlying secrets of schizophrenia. Up to day, over 1000 genes have been tested for association with the disease. The hope is that finding one gene or an association of genes would give way to identifying a specific protein which is in the background of the disturbance. As the research deepens, it becomes more and more clear how difficult it is to investigate the condition we call schizophrenia. On clinical grounds, it shares clinical features with a range of other psychiatric disorders and needs to be diagnosed with high accuracy. On the other hand, the transcription of proteins is much more complicated than previously predicted, even if genes involved with psychiatric illness are identified. (slide) As much as still is to be learned from the developing human genetics, we should keep in mind that even between monozygotic twins, sharing exactly the same genetic load, there is only less than 50% concordance for schizophrenia and moreover, most of the schizophrenic patients do not have a first degree sick relative.
13. The developing field of brain imaging is a second area which raises high expectations. The living structure and the functioning brain, seen in real time, are a challenge to the hope of understanding "what went wrong" (slide). The principal techniques used investigate either structure or function. The first findings, dating from the eighties and nineties with the introduction of the CT scan, showed (slide) the enlargement of the intra-cerebral ventricles and the atrophy of the grey matter in chronic schizophrenics compared to healthy subjects. These findings raised numerous objections. It was not clear whether these structural findings were the cause or the effect of the psychotic process. They may even have been the result of years of psychotropic medications. (slide).
Other techniques aimed at demonstrating the functioning brain include the fMRI (slide) with which for example we can detect functional differences between hallucinating and non hallucinating healthy controls. It is clearly observed from the images (slide) that additional neuronal centers are activated in the hallucinatory subjects. Yet the same question remains: Is the brain executing "an order" given be a higher hierarchical function, the way a motor neuron is activated to initiate a movement, but the decision to execute the order comes from elsewhere, or is there a detectable defect in the functioning brain tissue initiating perceptions without external stimuli. One more technique is the PET scan, demonstrating (slide) differences in the level of metabolism of different centers of the brain activated during different processes.
So actually we have ways of beginning to grasp the functioning brain, but whether these findings neglect the patient by concentrating on his brain or will help us to understand psychotics is still to be found out.
14. A new generation of psychotropic drugs appeared on the market at the beginning of the nineties. They were supposed to be the next pharmacological revolution, after the first one which took place in the fifties of the last century with the introduction of the first modern neuroleptic drug. They acted on new categories of neuro-transmitters and were expected to be more efficient and almost lacking side effects. Their launch was accompanied by a worldwide aggressive campaign by the pharmaceutical companies, with abundant money and gifts (more or less under disguise) distributed to institutions and psychiatrists to encourage their introduction. This Second Generation of Anti psychotics, albeit much more expensive, have become nowadays the first line of treatment. New classes of side effects, not encountered before, emerged. No more the Parkinsonian patients so typical to the old psychiatric wards, but more obese patients nowadays, in risk to develop Diabetes, Hyperlipidemias, and Cardio Vascular complications. Two major studies, the CATIE in the US and the EUFEST in Europe, financed by public funds devoid of commercial interests, show the equal efficacy of First and Second generation anti psychotic drugs (slide) leaving to the clinician and the patient with the choice of the least desirable side effects.
15. Common to all these research endeavors to connect brain sciences with mental disease is the effort to formulate structures and categories – biological or clinical, in contrast with psychoanalysis, which keeps looking for meaning and for the personal.
16. From all those afflicted with psychotic tendencies, who will become schizophrenic and what lesson should we keep in mind in 2013 from Jung's teachings?
(slide) As we can see from this slide, the prevalence of psychosis exceeds by far the prevalence of schizophrenia. It is astonishing to see how close this modern observation is to Jung's observation. In 1957, five years after the psychopharmacological revolution he writes: "The number of latent and potential psychoses is astoundingly large in comparison with the manifest cases. Without being able to give exact statistics, I reckon it at 10:1"
17. The problem is who, among those with a specific vulnerability, will become schizophrenic and who will remit.
At this point I wish to share my personal experience of over thirty years as a practicing psychiatrist working intensively with schizophrenics. I believe that schizophrenia is the disease of the poor and the unprivileged members of society. The typical schizophrenic patient (and of course not everyone) will be a young man or woman, generally coming from a disruptive family, often having just one active and
present parent, the parent often being unemployed, alcoholic or weak, belonging to a low socio economic status, often originating from an immigrant family either from a different culture or a victim of urbanization, often with minor criminal offences, often experiencing with drugs mainly OTC drugs, often with minor neurological deficits (like Attention Deficits or similar) ,usually not being able to afford good therapy, but, and most important, without hopes for a better future and without motivation to struggle for his sanity. Such a person, being probably constitutionally born with an inherited vulnerability, can one day, in reaction to stress or to a life event, decompensate to an acute psychosis or to a subclinical (prodromal) one. From this point on, the fight for the supremacy of the ego consciousness, the recruiting of willpower against the "Faiblesse De La Volonte", so beautifully described by Jung, must be based on the perspectives one could expect from regaining the reality testing, i.e. from meeting life. What does his future offer? In a competitive, technologically based, stratified society, when one feels unadapted, it is so tempting to give in and to submit to the lure of the collective unconscious.
18. Large epidemiological surveys sustain this thesis. Good epidemiological surveys are based on draft board registries like the Swedish one shown in the slide. (slide). The Israeli National Draft Board registry is very illuminating (Slide) as it combines assessment of all adolescents with the national registry of psychiatric hospitalization. We can learn from it that a previous non psychotic psychiatric diagnosis predisposes up to certain degree an upcoming diagnosis of schizophrenia. More illuminating is the next slide (slide) demonstrating that the lower the socio economic background the higher the chance to be hospitalized and diagnosed with schizophrenia. Being an immigrant, and furthermore being an immigrant from a distant society will be a risk factor as well (slide). Being an immigrant from former USSR to Israel could be a risk factor for mental disease but being an immigrant from rural Ethiopia and having to adjust to a very different way of living would be much more dangerous.
19. Back to the patients with whom I opened this presentation. M., the young professional who accompanied his wife to the maternity room and decompensated to psychosis soon afterwards, is by all means a courageous man. He fights for his ego consciousness, struggles painfully to remain in touch with reality and has fairly good chances for his future. On the other hand, M. is Israeli born, he lives and works in the environment and in the language in which he grew up, he was brought up in a good enough functioning family, he is married and has an average income. Maybe the most important additional factor is that he is lucky to be able to afford a reasonable good continuous therapy.
The Bedouin young woman is in a totally different situation, for her ego consciousness means facing an unbearable situation. For her, there is no way back and even if there was a way she wouldn't take it. For her the images of the collective unconscious even when tormenting are a better alternative.
20. The lessons to be learnt from Jung's heritage in the field of treating psychosis are multi faceted. Even inside our community and surely in the general public Jung is looked upon as being much of a mystic, a spiritual and religious thinker. The other aspects of his teachings, his being a sharp and well grounded clinician are often forgotten and neglected. Sometimes he might have been overly optimistic by asserting, for example in 1957: " It is now about fifty years since I became convinced, through practical experience that schizophrenic disturbances could be treated and cured by psychological means". Even so , now in the "Era of the Brain", when we can look at and observe the functioning brain in real time, when the human genetic code divulges its secrets, when we look upon mental disease through the perspective of statistics, clusters of symptoms, cost-effectiveness, when we look at the homogenous and not at the particular, it is especially invigorating for the therapist to remember Jung's words in 1939 : (slide) "The other fact that impressed me is the discovery I made when I began my psychotherapeutic practice: I was amazed at the number of schizophrenics whom we almost never see in psychiatric hospitals. These patients insist upon treatment and I found myself, Bleuler's loyal disciple trying my hand on cases we never would have dreamed of touching if we had them in the clinic, cases unmistakably schizophrenic even before treatment. I felt hopelessly unscientific in treating them at all – and after the treatment I was told that they could never have been schizophrenic" and he continues : "Even if I am not very hopeful about a patient, I try to give him as much psychology as he can stand, because I have seen plenty of cases where the later attacks were less severe and the prognosis was better as a result of increased psychological understanding". There are limitations of course to Jung's understanding of schizophrenia, he never elaborated, for example, on the peculiarity of the schizophrenic complex, how and why it is so different, energetically, from the over inflated neurotic complex and why it is self-devouring. He never elaborated on the reasons for the alienation one feels from his surroundings luring him to give up. But he emphasized the central place of one's responsibility to one's mental sanity, and the respect we should all have for those who do not let themselves be swayed away by the intrusion of those strange contents stemming from the unconscious.