Support from Studies of Schizophrenia

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R is assumed to identify what is important with each key problem by leaving images in the cortex that L reads. If R does this erratically it will lead to sudden changes in what L recognizes as important. This accounts for thought disorder where there is thought blocking, a sudden halting of thought, and failure to adhere to a theme. Thus the occurrence of thought disorder was put forward earlier as one of the reasons why R is expected to be abnormal in the disorder.

R’s lack of concentration

The alpha band of the EEG is inhibitory [24]. It is normally desynchronized temporarily after the occurrence of a novel stimulus, allowing attention to be given to the stimulus. Yet Kayser et al. [25] found that the desynchronization was diminished among patients at high risk of developing the disorder, especially at 9Hz and among patients who later become psychotic. This reflects an inability to concentrate on a new topic. The abnormal reaction was found only on the right, as if R cannot attend fully to a new topic, again implying that R is malfunctioning

R is unable to function veridically, and therefore creates false information

Unable to work with the truth, it is assumed that R creates false information that intensifies one of the problems. This resolves the dilemma. Thus R can create hallucinations that lower hope of certainty and turn attention to the certainty problem. Experiences of the environment that are not reliably repeated lower hope of certainty about it. Thus hallucinations that occur sometimes but not others will lower certainty. Verbal hallucinations are typically self-derogatory. They additionally lower hope of certainty because they threaten the place of the patient in society. Alternatively R creates grandiose and persecutory ideas that entail a false difficult task that lowers hope of freedom and turn attention to that. Atypically some patients have hallucinations that tell them to perform antisocial acts. This will draw attention to the restrictions against such acts and hence intensify the freedom problem. Also where hallucinations occur at regular intervals the regularity can help with certainty instead of lowering hope about it. This will turn attention away from the certainty problem and help to turn it to the freedom problem.

L is continually using the results of R’s activities with the certainty problem, such as in providing images of objects that have size, shape and color constancy. Hence L automatically accepts the hallucinations and false task as real.

In a key study discussed more fully previously [2,20], McGlashan et al. [26] describe a continuum between two patients, Maria and Cynthia. Maria had an unsettled early life, hence a chronic certainty problem, and a recent loss of freedom in a restrictive job, hence a temporary freedom problem. She had hallucinations. Indeed several studies link hallucinations with an unsettled history [27].

Cynthia had a restrictive family background, and hence a chronic freedom problem. Several studies of settled homes point to them being restrictive in various ways [2]. In addition Cynthia had a temporary certainty problem caused by recently being rejected by a prospective spouse. She had persecutory ideas that entailed a false difficult task of overcoming the opposition of a powerful group of people. This would have limited her freedom and turned attention to that. The backup is only active with the freedom problem. Hence the importance of the freedom problem with Cynthias is shown by evidence that only they have the backup, as described in Appendix1.

With Maria and Cynthia one problem was chronic and one temporary. Both patients turned attention to their chronic problem. Similar activity might have occurred in the past. Thus patients have a history of the false attribution of reality that will have been linked with their chronic problem. When they were children, they could lie for no reason [28]. When students they reported perceptual aberrations, mistaken sights and sounds [29].

Gruzelier et al. [30] found that some patients, who would have been Marias, had poor recognition memory for words. This indicated a right hemisphere specialization. Others, who would have been Cynthias, had poor recognition memory for faces. This indicated a left hemisphere specialization. Recovery was accompanied by loss of these memory defects as if the specialization was no longer necessary. Still memory for faces will be important with the certainty problem, whereas memory for words reflects the left hemisphere and hence the freedom problem. Therefore the observations equally show that, in recovery, attention is less confined to either the certainty or freedom problems.

The argument requires hallucinations to be regarded as deliberate creations by R. Accordingly a study by Kopecek et al. [31] found that patients with prominent verbal hallucinations, as compared to patients who have none, have more activity in the right middle frontal gyrus. Sommer et al. [32] compared hallucinating with non-hallucinating states in the same patients, using an adequate number of patients. Hallucinations were again linked with raised activity in the right middle frontal gyrus. As the homolog on the left is associated with willed activity [33] this is expected to reflect the “willed” activity of R that would be needed to initiate the creation of hallucinations. In addition the right insula was especially active during hallucinations, as if to reflect R’s effort [34]. During its exerting influence microstate C, R would be free to exploit the speech areas on the left. Thus during hallucinations activity increased in Broca’s area and its homolog and other speech related areas [31].

In order to overcome the language difference, R’s images have to resemble sensory inputs. Thus the images are deposited in speech perception areas on the left, where Y’s accepting influence microstate A is active. This is shown by fMRI findings and by the reduced ability of the right ear [35].

As noted earlier, in the disorder generally, microstate D, where L exerts influence, is shorter, whereas type A, where L accepts influence, is not. A study by Kindler et al. [36] found that type D also shortens during hallucinations, type A still not being affected. This is consistent with L accepting influence in the normal way and the images of hallucinations that R deposits being responsible for the shortening of D.

As R exerts influence in creating the necessary images, interhemispheric coherence is expected at low theta. Thus Weller and Montagu [37] found raised coherence between the temporal lobes at frequencies in the range 3-5 Hz. They used bipolar recordings so as to avoid a single reference site. This technique was approved by later investigators who found that different single reference sites produced different assessments of coherence.

The loss of connectivity

The blocking of speech perception via the right ear might reflect the reduced use and consequent atrophy of areas that deal with speech perception. Accordingly Kasai et al.[38] found that Heschl’s gyrus, which is a primary speech perception area, and an adjacent part of the planum temporale, have progressively reduced grey matter during the disorder. Some corresponding loss of connectivity can be expected.

Still loss of connectivity can also be expected to result from the backup. In the longer term, the suppression of the left parietal during the cut-out will entail the inactivity of the normal connections on the left and their consequent atrophy. With the override, R takes over the sensory inputs and motor outputs on the left. Yet this still might leave open the use of imagery for fantasy. Thus some evidence suggests that in the disorder fantasy is associated with immobility [39]. This is a sign of the override when there is no one in apparent authority giving commands and suggestions [8]. If the override and fantasy often occur concurrently but separately, they might add to the loss of connectivity rather than to atrophy of the gray matter. Accordingly Benetti et al. [40] found that the connectivity loss occurred especially with patients without hallucinations, who would be Cynthias and have the backup.

The recurrent confusion

As mentioned earlier, the isolated and recurrent forms of the disorder are both regarded as caused by competition between the certainty and freedom problems. The recurrent form occurs when vulnerability to this stress is raised, so that the confusion occurs more readily. Any genetic or chromosome abnormality that affects the brain is likely to weaken the position of R, increasing the risk of the recurrent disorder. R’s position will be weakened when the corpus callosum is relatively large or small [41], so that it joins the hemispheres too soon or too late. The switching between the problems will develop less well and R will fail sooner.

R might be weakened by disruptive past events that hamper its dealings with the certainty problem. Also as there is no direct communication between R and L, R will be partly dependent on overt activity and speech for information about L. Hence a life style of isolation or inactivity will starve R of knowledge of L.

The developments after 21 years might create a lasting vulnerability. Thus the sudden transition from one problem to another every 18 months night involve chemical triggers that raise R’s sensitivity to some aspect of the key problem. The nine year sequence of key problems is worked through at least twice and the triggers might continue through life. Their effects will weaken because of increased body mass. Alongside this R attempts to match the key problem to the social situation, probably are being influenced by other people’s facial expressions as well as by past history that emphasizes one or two of the problems.

Accordingly it is assumed that there is at least a third repetition of the sequence, with certainty at 18-19.5, freedom at 19.5-21, and satisfaction at 21-22.5 years. After 21, the satisfaction problem draws attention to doing, hence the freedom problem, and experiencing, hence the certainty problem, at the same time. Possibly a chemical trigger raises sensitivity about disgust. Doing that avoids the experience of disgust might become especially attractive.

The Rs of typical people might have sufficient confidence with the certainty and freedom problems to be able to combine them. Yet a severe competition between the certainty and freedom problems, caused by low confidence with both, might obstruct this. R is then left with a dilemma of choosing between the certainty and freedom problems. These conditions might make the dilemma especially troublesome for R. Once created they might be readily re-created, causing continued vulnerability.

The satisfaction problem came to attention at 3-4.5 and again at 12- 13.5 years. What happens after 21 probably largely depends on what happened at these times. Still [3] the pressure to perform particular work on a problem depends on the difference between present hope and the anticipated hope, the hope anticipated when the work is done. Thus it is not only low present hopes about the problems but also high anticipations that intensify the competition at this time, leading to failure to deal with the satisfaction problem in spite of earlier success.

R is central, L is peripheral but can still be important

Besides the argument about R’s dilemma causing its malfunction, further evidence described in Appendix 2 implicates the malfunctioning or abnormality of R. Yet L functions normally in the sense that it accepts influence from R in the normal way. R feeds L abnormal images and L follows. In this way R is central to the disorder.

Nevertheless Ls control the environment. Thus people at risk or in a prodromal state might become aware of the severity of their condition and the need to find as easier life style. A successful reduction of commitments might depend on the ability to make and apply deliberate decisions and on intelligence, as well as on receiving advice and having the means to make changes. Thus Mechelli et al. [42] found that among people at risk for the disorder only those with low left parahippocampal volume developed psychosis. Pantelis et al. [43] found that people prodromal for the disorder had relatively less gray matter on the right, consistent with R’s abnormality. Yet those who later became psychotic had less grey matter in the left parahippocampal area, and other areas on the left that could affect intelligence. Now the hippocampus is involved in deliberate decision making. Hence a deficient left parahippocampal area can be expected to weaken this. Thus the role of L is peripheral but can still be important. The finding might apply only to patients who have the power to alter the environment or pattern of behavior. It might therefore relate to social class.

R’s functioning is normally intelligent and understandable

There is evidence that the right hemisphere, and hence R, is involved in work on the certainty problem in infancy [6]. As mentioned earlier, for example, object constancy develops, where objects are seen as the same regardless of distance, orientation and lighting. The tasks involved must place some intellectual demands on R, and this implies that R can function intelligently.

The nine year sequence of the key problems derives from a sequence of influences that probably involve chemical triggers. These turn R’s attention to each of the key problems in turn in childhood and later. Yet alongside it, and becoming more prominent, is a direction of L’s attention to the key problem that matches the social implications of the current situation. This might be an extension of R’s continuing work on the certainty problem because in matching L’s attention to the current social conditions it makes L’s behavior more predictable. This again appears to be intellectually challenging.

The certainty problem involves observations of the environment when one is at rest. It therefore requires an image of rest as a label. Some soft object that the infant has had in the cot from three months of age, begins to be essential to rest. Infants will insist on having this object with them when they go to sleep. Busch et al. [44] found that parents reported incidents like the following. One night a six-month-old boy would not go to sleep. In order to try to comfort him they gave him his toy penguin, he immediately calmed down and went to sleep. The object has been called the ‘first transitional object’, but here it is called the rest object. Wolf and Lozoff [45] found that if infants shared the mother’s bedroom then there was no actual object as a rest object. Still in these conditions mothers almost invariably held their infants during the passage to sleep. This could have created conditions where part of the mother or her clothing became the rest object. Thus Busch et al. report an instance where part of the mother’s clothing became the rest object.

It is understandable that a visual image derived from the rest object is used by R to label the certainty problem. Support for this comes from how the rest object is typically lacking in autism. This disorder can be attributed to the disorganization caused by the lack of a label for certainty [20].

The freedom problem involves gaining success at any task. Thus an image of an all-powerful person might be used to represent it. Accordingly Abelin [46] observed that infants encouraged their fathers to play roughly with them, as if to help to create this image.

The satisfaction problem is one of gaining sufficient good outcomes for the self, through one’s activities. One might understand it being be represented by an image that combines form and color. Form could stand for the activity required and color could stand for good outcomes. Support for the use of a color-form image comes from evidence of slowed performance with such images among children with attention deficit hyperactivity disorder [47]. These children lack experience of good independently achieved effort-outcome sequences. Thus Carlson et al. [48] observed children of 3.5 years with their mothers. Children are preoccupied with the satisfaction problem at this age and their experiences will relate to that. Those children who later developed inattentiveness and hyperactivity had mothers who would stroke the hair or face of their child, stay close and lean towards the child, who would lean away. They also teased and provoked the child. This implies a relative lack of experience of independently achieved effort-outcome sequences by the child. This could disrupt the use of a color-form image to represent the satisfaction problem and cause the slowing with color-form images generally.

When the certainty problem comes to attention for the second time at 9 to 10.5 years, R has to convey to L the importance of the certainty problem. There are bad dreams, such as the destruction of trucks and houses by fire or tornado, being chased, shot or kidnapped, death of the mother or best friend, or of the mother running away [49]. These would tend to draw attention to the certainty problem. As they come at an appropriate time the dream images are understandable as being left by R.

Much of R’s functioning is hidden from view. Yet from what one can observe it appears to be intelligent and understandable.

R listens in to speech

In the first 18 months infants mainly work on the certainty problem such as in developing object constancy. This is done by R and the right hemisphere is dominant at this time, as tf R is in control. Infants then learn to speak only one or two words and their understanding of other’s speech is very limited. Hence Rs could not acquire much language ability at this time. Yet when people are in deep hypnosis in later life, when R is in control and L is suppressed, they are able to understand other people. For example they can take part in experiments and obey the necessary instructions [8]. This means that R must have been listening in to speech and acquiring an ability to understand it even though R does not speak.

Is the malfunction of R central to psychosis?

The existence of R helps in developing a view of schizophrenia that accounts for a wide range of research. Yet as R deals with the certainty problem, repeated major changes to the environment that create sufficient uncertainty might cause R to fail to function helpfully. Attention will remain confined to the certainty problem, leading to L’s persistent use of depressive strategies, such as staying in a well-known place like the home, narrowing the field of one’s activities, freezing, remaining immobile (Table 1). Thus there is well known empirical link between environmental change and depression. In these circumstances the consequent behavior might be attributed to depressive psychosis. This raises the question of whether, although the normal functioning of R is intelligent and understandable, its malfunctioning is central to psychosis in general.

Implications for Treatment

Risperidone might match the trigger for the other’s good state problem

Every eighteen months in childhood the sensitivity to one of the key problems is suddenly raised, lowering hope about it and turning attention to it. How this is achieved has not yet been studied. With some of the problems the release of a chemical trigger might induce the change. If a drug matches the trigger its regular use might continually confine attention to one key problem.

Risperidone might resemble the trigger for the other’s good state problem. This problem is linked to parenthood, as it is children who especially need help. Accordingly risperidone stimulates prolactin and reduces sexual interest and potency [50]. In a game, as compared to trifluoperazine, it made patients cooperative and trusting of partners and hence more helpful [51].

A strategy that might be lost because of a persistent focus of attention on other people is that of working systematically-organizing one’s own behavior to optimal effect. This might account for the observation by Purdon et al. [52] that patients receiving risperidone failed to improve and even declined in performance with repetition of the Tower of Toronto puzzle, which appears to call for a systematic approach. Typical people might switch to the satisfaction problem in dealing with the puzzle, and one of the listed strategies for this problem is working systematically [3]. Patients on risperidone might be unable to do this.

Lastly there is no benefit from high doses. A dose that is sufficient to turn attention to the problem has similar effects to a larger one. Doses above a standard dose of 4-6 mg a day give no extra benefit [53]. In a study of long acting injections of the drug, 50 and 100 mg a fortnight had identical effects [54].

An implied treatment

In the theory hope and confidence both mean the believed probability of attaining sufficient certainty. Here the term confidence might be preferred. One aim is to raise the ‘confidence’ of R about the certainty and freedom problems so as to lower the stress caused by its dilemma. Another is to clarify L’s behavior for R. The suggested treatment involves exercises to raise confidence about the problems and conversation about the problems and how they relate to the patient’s life.

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Support from Studies of Schizophrenia

Posted on

R is assumed to identify what is important with each key problem by leaving images in the cortex that L reads. If R does this erratically it will lead to sudden changes in what L recognizes as important. This accounts for thought disorder where there is thought blocking, a sudden halting of thought, and failure to adhere to a theme. Thus the occurrence of thought disorder was put forward earlier as one of the reasons why R is expected to be abnormal in the disorder.

R’s lack of concentration

The alpha band of the EEG is inhibitory [24]. It is normally desynchronized temporarily after the occurrence of a novel stimulus, allowing attention to be given to the stimulus. Yet Kayser et al. [25] found that the desynchronization was diminished among patients at high risk of developing the disorder, especially at 9Hz and among patients who later become psychotic. This reflects an inability to concentrate on a new topic. The abnormal reaction was found only on the right, as if R cannot attend fully to a new topic, again implying that R is malfunctioning

R is unable to function veridically, and therefore creates false information

Unable to work with the truth, it is assumed that R creates false information that intensifies one of the problems. This resolves the dilemma. Thus R can create hallucinations that lower hope of certainty and turn attention to the certainty problem. Experiences of the environment that are not reliably repeated lower hope of certainty about it. Thus hallucinations that occur sometimes but not others will lower certainty. Verbal hallucinations are typically self-derogatory. They additionally lower hope of certainty because they threaten the place of the patient in society. Alternatively R creates grandiose and persecutory ideas that entail a false difficult task that lowers hope of freedom and turn attention to that. Atypically some patients have hallucinations that tell them to perform antisocial acts. This will draw attention to the restrictions against such acts and hence intensify the freedom problem. Also where hallucinations occur at regular intervals the regularity can help with certainty instead of lowering hope about it. This will turn attention away from the certainty problem and help to turn it to the freedom problem.

L is continually using the results of R’s activities with the certainty problem, such as in providing images of objects that have size, shape and color constancy. Hence L automatically accepts the hallucinations and false task as real.

In a key study discussed more fully previously [2,20], McGlashan et al. [26] describe a continuum between two patients, Maria and Cynthia. Maria had an unsettled early life, hence a chronic certainty problem, and a recent loss of freedom in a restrictive job, hence a temporary freedom problem. She had hallucinations. Indeed several studies link hallucinations with an unsettled history [27].

Cynthia had a restrictive family background, and hence a chronic freedom problem. Several studies of settled homes point to them being restrictive in various ways [2]. In addition Cynthia had a temporary certainty problem caused by recently being rejected by a prospective spouse. She had persecutory ideas that entailed a false difficult task of overcoming the opposition of a powerful group of people. This would have limited her freedom and turned attention to that. The backup is only active with the freedom problem. Hence the importance of the freedom problem with Cynthias is shown by evidence that only they have the backup, as described in Appendix1.

With Maria and Cynthia one problem was chronic and one temporary. Both patients turned attention to their chronic problem. Similar activity might have occurred in the past. Thus patients have a history of the false attribution of reality that will have been linked with their chronic problem. When they were children, they could lie for no reason [28]. When students they reported perceptual aberrations, mistaken sights and sounds [29].

Gruzelier et al. [30] found that some patients, who would have been Marias, had poor recognition memory for words. This indicated a right hemisphere specialization. Others, who would have been Cynthias, had poor recognition memory for faces. This indicated a left hemisphere specialization. Recovery was accompanied by loss of these memory defects as if the specialization was no longer necessary. Still memory for faces will be important with the certainty problem, whereas memory for words reflects the left hemisphere and hence the freedom problem. Therefore the observations equally show that, in recovery, attention is less confined to either the certainty or freedom problems.

The argument requires hallucinations to be regarded as deliberate creations by R. Accordingly a study by Kopecek et al. [31] found that patients with prominent verbal hallucinations, as compared to patients who have none, have more activity in the right middle frontal gyrus. Sommer et al. [32] compared hallucinating with non-hallucinating states in the same patients, using an adequate number of patients. Hallucinations were again linked with raised activity in the right middle frontal gyrus. As the homolog on the left is associated with willed activity [33] this is expected to reflect the “willed” activity of R that would be needed to initiate the creation of hallucinations. In addition the right insula was especially active during hallucinations, as if to reflect R’s effort [34]. During its exerting influence microstate C, R would be free to exploit the speech areas on the left. Thus during hallucinations activity increased in Broca’s area and its homolog and other speech related areas [31].

In order to overcome the language difference, R’s images have to resemble sensory inputs. Thus the images are deposited in speech perception areas on the left, where Y’s accepting influence microstate A is active. This is shown by fMRI findings and by the reduced ability of the right ear [35].

As noted earlier, in the disorder generally, microstate D, where L exerts influence, is shorter, whereas type A, where L accepts influence, is not. A study by Kindler et al. [36] found that type D also shortens during hallucinations, type A still not being affected. This is consistent with L accepting influence in the normal way and the images of hallucinations that R deposits being responsible for the shortening of D.

As R exerts influence in creating the necessary images, interhemispheric coherence is expected at low theta. Thus Weller and Montagu [37] found raised coherence between the temporal lobes at frequencies in the range 3-5 Hz. They used bipolar recordings so as to avoid a single reference site. This technique was approved by later investigators who found that different single reference sites produced different assessments of coherence.

The loss of connectivity

The blocking of speech perception via the right ear might reflect the reduced use and consequent atrophy of areas that deal with speech perception. Accordingly Kasai et al.[38] found that Heschl’s gyrus, which is a primary speech perception area, and an adjacent part of the planum temporale, have progressively reduced grey matter during the disorder. Some corresponding loss of connectivity can be expected.

Still loss of connectivity can also be expected to result from the backup. In the longer term, the suppression of the left parietal during the cut-out will entail the inactivity of the normal connections on the left and their consequent atrophy. With the override, R takes over the sensory inputs and motor outputs on the left. Yet this still might leave open the use of imagery for fantasy. Thus some evidence suggests that in the disorder fantasy is associated with immobility [39]. This is a sign of the override when there is no one in apparent authority giving commands and suggestions [8]. If the override and fantasy often occur concurrently but separately, they might add to the loss of connectivity rather than to atrophy of the gray matter. Accordingly Benetti et al. [40] found that the connectivity loss occurred especially with patients without hallucinations, who would be Cynthias and have the backup.

The recurrent confusion

As mentioned earlier, the isolated and recurrent forms of the disorder are both regarded as caused by competition between the certainty and freedom problems. The recurrent form occurs when vulnerability to this stress is raised, so that the confusion occurs more readily. Any genetic or chromosome abnormality that affects the brain is likely to weaken the position of R, increasing the risk of the recurrent disorder. R’s position will be weakened when the corpus callosum is relatively large or small [41], so that it joins the hemispheres too soon or too late. The switching between the problems will develop less well and R will fail sooner.

R might be weakened by disruptive past events that hamper its dealings with the certainty problem. Also as there is no direct communication between R and L, R will be partly dependent on overt activity and speech for information about L. Hence a life style of isolation or inactivity will starve R of knowledge of L.

The developments after 21 years might create a lasting vulnerability. Thus the sudden transition from one problem to another every 18 months night involve chemical triggers that raise R’s sensitivity to some aspect of the key problem. The nine year sequence of key problems is worked through at least twice and the triggers might continue through life. Their effects will weaken because of increased body mass. Alongside this R attempts to match the key problem to the social situation, probably are being influenced by other people’s facial expressions as well as by past history that emphasizes one or two of the problems.

Accordingly it is assumed that there is at least a third repetition of the sequence, with certainty at 18-19.5, freedom at 19.5-21, and satisfaction at 21-22.5 years. After 21, the satisfaction problem draws attention to doing, hence the freedom problem, and experiencing, hence the certainty problem, at the same time. Possibly a chemical trigger raises sensitivity about disgust. Doing that avoids the experience of disgust might become especially attractive.

The Rs of typical people might have sufficient confidence with the certainty and freedom problems to be able to combine them. Yet a severe competition between the certainty and freedom problems, caused by low confidence with both, might obstruct this. R is then left with a dilemma of choosing between the certainty and freedom problems. These conditions might make the dilemma especially troublesome for R. Once created they might be readily re-created, causing continued vulnerability.

The satisfaction problem came to attention at 3-4.5 and again at 12- 13.5 years. What happens after 21 probably largely depends on what happened at these times. Still [3] the pressure to perform particular work on a problem depends on the difference between present hope and the anticipated hope, the hope anticipated when the work is done. Thus it is not only low present hopes about the problems but also high anticipations that intensify the competition at this time, leading to failure to deal with the satisfaction problem in spite of earlier success.

R is central, L is peripheral but can still be important

Besides the argument about R’s dilemma causing its malfunction, further evidence described in Appendix 2 implicates the malfunctioning or abnormality of R. Yet L functions normally in the sense that it accepts influence from R in the normal way. R feeds L abnormal images and L follows. In this way R is central to the disorder.

Nevertheless Ls control the environment. Thus people at risk or in a prodromal state might become aware of the severity of their condition and the need to find as easier life style. A successful reduction of commitments might depend on the ability to make and apply deliberate decisions and on intelligence, as well as on receiving advice and having the means to make changes. Thus Mechelli et al. [42] found that among people at risk for the disorder only those with low left parahippocampal volume developed psychosis. Pantelis et al. [43] found that people prodromal for the disorder had relatively less gray matter on the right, consistent with R’s abnormality. Yet those who later became psychotic had less grey matter in the left parahippocampal area, and other areas on the left that could affect intelligence. Now the hippocampus is involved in deliberate decision making. Hence a deficient left parahippocampal area can be expected to weaken this. Thus the role of L is peripheral but can still be important. The finding might apply only to patients who have the power to alter the environment or pattern of behavior. It might therefore relate to social class.

R’s functioning is normally intelligent and understandable

There is evidence that the right hemisphere, and hence R, is involved in work on the certainty problem in infancy [6]. As mentioned earlier, for example, object constancy develops, where objects are seen as the same regardless of distance, orientation and lighting. The tasks involved must place some intellectual demands on R, and this implies that R can function intelligently.

The nine year sequence of the key problems derives from a sequence of influences that probably involve chemical triggers. These turn R’s attention to each of the key problems in turn in childhood and later. Yet alongside it, and becoming more prominent, is a direction of L’s attention to the key problem that matches the social implications of the current situation. This might be an extension of R’s continuing work on the certainty problem because in matching L’s attention to the current social conditions it makes L’s behavior more predictable. This again appears to be intellectually challenging.

The certainty problem involves observations of the environment when one is at rest. It therefore requires an image of rest as a label. Some soft object that the infant has had in the cot from three months of age, begins to be essential to rest. Infants will insist on having this object with them when they go to sleep. Busch et al. [44] found that parents reported incidents like the following. One night a six-month-old boy would not go to sleep. In order to try to comfort him they gave him his toy penguin, he immediately calmed down and went to sleep. The object has been called the ‘first transitional object’, but here it is called the rest object. Wolf and Lozoff [45] found that if infants shared the mother’s bedroom then there was no actual object as a rest object. Still in these conditions mothers almost invariably held their infants during the passage to sleep. This could have created conditions where part of the mother or her clothing became the rest object. Thus Busch et al. report an instance where part of the mother’s clothing became the rest object.

It is understandable that a visual image derived from the rest object is used by R to label the certainty problem. Support for this comes from how the rest object is typically lacking in autism. This disorder can be attributed to the disorganization caused by the lack of a label for certainty [20].

The freedom problem involves gaining success at any task. Thus an image of an all-powerful person might be used to represent it. Accordingly Abelin [46] observed that infants encouraged their fathers to play roughly with them, as if to help to create this image.

The satisfaction problem is one of gaining sufficient good outcomes for the self, through one’s activities. One might understand it being be represented by an image that combines form and color. Form could stand for the activity required and color could stand for good outcomes. Support for the use of a color-form image comes from evidence of slowed performance with such images among children with attention deficit hyperactivity disorder [47]. These children lack experience of good independently achieved effort-outcome sequences. Thus Carlson et al. [48] observed children of 3.5 years with their mothers. Children are preoccupied with the satisfaction problem at this age and their experiences will relate to that. Those children who later developed inattentiveness and hyperactivity had mothers who would stroke the hair or face of their child, stay close and lean towards the child, who would lean away. They also teased and provoked the child. This implies a relative lack of experience of independently achieved effort-outcome sequences by the child. This could disrupt the use of a color-form image to represent the satisfaction problem and cause the slowing with color-form images generally.

When the certainty problem comes to attention for the second time at 9 to 10.5 years, R has to convey to L the importance of the certainty problem. There are bad dreams, such as the destruction of trucks and houses by fire or tornado, being chased, shot or kidnapped, death of the mother or best friend, or of the mother running away [49]. These would tend to draw attention to the certainty problem. As they come at an appropriate time the dream images are understandable as being left by R.

Much of R’s functioning is hidden from view. Yet from what one can observe it appears to be intelligent and understandable.

R listens in to speech

In the first 18 months infants mainly work on the certainty problem such as in developing object constancy. This is done by R and the right hemisphere is dominant at this time, as tf R is in control. Infants then learn to speak only one or two words and their understanding of other’s speech is very limited. Hence Rs could not acquire much language ability at this time. Yet when people are in deep hypnosis in later life, when R is in control and L is suppressed, they are able to understand other people. For example they can take part in experiments and obey the necessary instructions [8]. This means that R must have been listening in to speech and acquiring an ability to understand it even though R does not speak.

Is the malfunction of R central to psychosis?

The existence of R helps in developing a view of schizophrenia that accounts for a wide range of research. Yet as R deals with the certainty problem, repeated major changes to the environment that create sufficient uncertainty might cause R to fail to function helpfully. Attention will remain confined to the certainty problem, leading to L’s persistent use of depressive strategies, such as staying in a well-known place like the home, narrowing the field of one’s activities, freezing, remaining immobile (Table 1). Thus there is well known empirical link between environmental change and depression. In these circumstances the consequent behavior might be attributed to depressive psychosis. This raises the question of whether, although the normal functioning of R is intelligent and understandable, its malfunctioning is central to psychosis in general.

Implications for Treatment

Risperidone might match the trigger for the other’s good state problem

Every eighteen months in childhood the sensitivity to one of the key problems is suddenly raised, lowering hope about it and turning attention to it. How this is achieved has not yet been studied. With some of the problems the release of a chemical trigger might induce the change. If a drug matches the trigger its regular use might continually confine attention to one key problem.

Risperidone might resemble the trigger for the other’s good state problem. This problem is linked to parenthood, as it is children who especially need help. Accordingly risperidone stimulates prolactin and reduces sexual interest and potency [50]. In a game, as compared to trifluoperazine, it made patients cooperative and trusting of partners and hence more helpful [51].

A strategy that might be lost because of a persistent focus of attention on other people is that of working systematically-organizing one’s own behavior to optimal effect. This might account for the observation by Purdon et al. [52] that patients receiving risperidone failed to improve and even declined in performance with repetition of the Tower of Toronto puzzle, which appears to call for a systematic approach. Typical people might switch to the satisfaction problem in dealing with the puzzle, and one of the listed strategies for this problem is working systematically [3]. Patients on risperidone might be unable to do this.

Lastly there is no benefit from high doses. A dose that is sufficient to turn attention to the problem has similar effects to a larger one. Doses above a standard dose of 4-6 mg a day give no extra benefit [53]. In a study of long acting injections of the drug, 50 and 100 mg a fortnight had identical effects [54].

An implied treatment

In the theory hope and confidence both mean the believed probability of attaining sufficient certainty. Here the term confidence might be preferred. One aim is to raise the ‘confidence’ of R about the certainty and freedom problems so as to lower the stress caused by its dilemma. Another is to clarify L’s behavior for R. The suggested treatment involves exercises to raise confidence about the problems and conversation about the problems and how they relate to the patient’s life.

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