Support from Studies of Schizophrenia

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In a ‘confirmation exercise’ someone looks at something, closes the eyes and remembers it, then looks again to confirm that it is as remembered. This might be repeated, such as five times or more. It is assumed that this provides an experience of certainty about the environment that raises hope of certainty. Here a booklet with pictures of objects and scenes would be helpful. It might start very simply, such as with black and white and the primary colors, but remain simple. The most helpful level of complexity might be determined by experience.

An exercise for the freedom problem is to engage in confirmation exercises before and after producing an effect. Here jigsaw puzzles would be helpful. Confirmation could occur before and after fitting each piece. Simple jigsaws, where the addition of a piece produces a noticeable change, would be required. Difficult jigsaws have similar pieces where the placing of a piece can make little difference to the resulting picture.

Conversations about ways of raising confidence about certainty and freedom, the conditions that lower confidence, and how the problems relate to someone’s life, can be used. R is assumed to listen in to them and gain confidence about the problems and in understanding L. Thus the reports by Carlson [55] and McGlashan et al. [26] suggest that this is helpful. Carlson treated students who were in a confusional state. She identified two simultaneous stresses that would have reflected the competing certainty and freedom problems. They had either just entered college or were soon to leave, lowering hope of certainty. At the same time they were either in the grip of a first affair or were being pressured by parents about vocational choice, lowering hope of freedom. In effect the certainty and freedom problems will have been clarified and related to the patient’s life. R will listened in and have confidence raised. Similarly McGlashan et al. found that Marias benefit from a discussion of the inescapable uncertainties of life. Rs specialize in the certainty problem and Marias have an unsettled early life with experiences of uncertainty. Hence the Rs of Marias are expected to follow a conversation about certainty relatively well and gain in confidence.

The Rs of Cynthias would have less background of experience of uncertainty and might gain less from listening in to its discussion. The effects of a loss of a companion would be countered by experiences of stability, expectations of a lasting relationship with a therapist or of membership in a therapeutic group. This might help R with the certainty problem so that it no longer competes with the freedom problem. Hence R might not have to re-assert the false task. It remains for L to overcome the past influence from R. The false task that derived from R’s false information, might be repeatedly put aside by L so as to concentrate on other tasks. This might become habitual and automatic. Thus McGlashan et al. report that Cynthias improved by ‘sealing over’. As Maria and Cynthia are at the ends of a continuum, most patients might benefit from a combination of the treatments. Yet Cynthias’ Rs still might benefit from listening in to a discussion of the inevitable restrictions that occur in life, and the different ways of, or strategies for, raising hope of freedom.

R will be accustomed to picking up information from casual conversations. Hence the treatment might best employ conversational conditions, at a sufficiently simple level. Material for conversation can be found in the strategy lists for each of the problems. In isolated societies everyone tends to concentrate on one key problem, and the behavior in them has been related to the strategy list for that problem [3]. There is a workbook that examines reasons why particular strategies are helpful [56]. Discussions of conditions that lower hope about certainty [57] and freedom [2] are available.

A sign of the greater confidence with the problems will be the emergence of concern about the satisfaction problem. This will lead to interest in tidying and various hobbies where one can see the goodness of the effects that one produces. This represents the normal pattern of development. It implies that R’s stress has been reduced sufficiently for its preoccupation with the dilemma to be given up, allowing the freedom and certainty problems to be combined within the satisfaction problem.

The exercises are based on theoretical expectations that they will raise R’s confidence in dealing with the problems involved in its dilemma. They might be impractical or unhelpful in practice. It is questionable whether the treatment can be combined with drug treatment. Typical antipsychotics have adverse effects on learning [58]. Yet risperidone for example might turn attention to the other’s good state problem and hence away from the certainty and freedom problems where the new learning is needed. Still what is happening in the brain might be too complex to be sure of this.

The treatment might help early in the disorder. Yet it would be better if people had been educated in accord with the key problems previously. If children could choose, they would engage in activities related to each key problem as it emerges in turn. This would help L in developing of patterns of work on the key problems and help R in distinguishing between the problems. An education that is integrated with progress through the key problems will facilitate this. Otherwise unrealistic strategies such as turning attention to facts that raise hope about the problem and away from facts that lower hope about it are encouraged. They will weaken L’s interest in working actively on the key problems and fail to clarify them for R.


An aspect of the functioning of the brain is the backup, which includes a cut-out and an override. It is needed when there is concern with the freedom problem. Observations related to it add strong support for problem theory in that they point to an adaption to it that has developed through evolution.

There is support for a system R developing on the right in parallel with the system on the left, L, which becomes the mind. It is R that selects the key problem by attributing importance to it. As R and L do not communicate directly there is no awareness of this. The study of R’s functioning suggests that it is normally intelligent and understandable.

Studies of schizophrenia have been reviewed because this disorder is associated with poor judgment of what is important. They repeatedly implicate R, supporting the argument that R controls the judgment of what is important.

An outcome of the review is an account of the disorder where some drugs might be helpful because they resemble the triggers for one of the later problems. Risperidone might resemble the trigger for the other’s good state problem. The review points to the possible helpfulness of exercises that raise R’s confidence in dealing with the certainty and freedom problems. Conversation about how the problems relate to the patient’s life helps because R listens in. Thus the acceptance of the existence of R leads to an account of schizophrenia that incorporates many findings and implies a form of treatment. The account also draws attention to how an education that is integrated with progress through the key problems in childhood would strengthen R.


Evidence of the backup in the disorder

The backup is not specific to abnormal conditions and is part of normal activity. Yet it becomes overactive in some patients and this could include Cynthias, who turn to the freedom problem. The reorganizations that are required by the backup will be disruptive temporarily. Hence both cut-out and override are expected to be imposed quickly. They might therefore contribute to thought blocking. Yet, once triggered they might persist. The cut-out will lead to a loss of creativity. With the override, aside from compulsive obedience to someone in apparent authority, nothing more than conventional responses are expected. Hence the immediate effect of the backup might be stereotypy of thought. Sabri et al. [59] studied never medicated patients of mean age 32 years, mean illness duration of 2.7 years, in an acute phase. A radiotracer was used to study blood flow while participants were at rest. Stereotyped thought was related to the lack of activity in the parietal and temporal lobes, as if both cut-out and override were involved.

EEG evidence of the backup in the disorder

One prediction can be made about the frequency bands involved. R is now thought to control the backup and it uses low frequency theta in exerting influence. Hence the initiations of the cut-out and override are expected to be associated with low theta.

Observations of coherence are affected by electrical changes at the EEG reference site and disagreements between early studies were attributed to errors that arose in this way. As mentioned earlier, one way of avoiding such errors is by using bipolar recordings. Here pairs of sites are used fairly close together in each area instead of one. Thus Ford et al. [60] worked in this way with medicated paranoid patients, mean age 26 years, who will have been Cynthias and have the backup, in comparison with patients with other disorders. They found interhemispheric coherence in the theta and alpha bands, at rest, between areas close to T5 and T6, which would reflect the override. It was noted earlier that Weller and Montagu [37] found interhemispheric coherence between temporal areas between 3 and 5 Hz, using bipolar recording. This indicates that the theta involved is low theta, consistent with R exerting influence. Kam et al. [22] studied medicated 40 year old female patients who had many residual symptoms (mean PANSS 62.1). The T5-T6 coherence was high for the alpha ranges but not for theta. Still this might reflect the override being triggered when the electrodes were applied. Hence the theta might have ended before the recording began. The coherence of low alpha, 8-10 Hz, was especially prominent both between and within hemispheres. As noted earlier, it has been claimed that alpha is inhibitory, consistent with R using this to suppress the left hemisphere. A study of local coherence over the whole scalp using many electrodes, in connection with Alzheimer’s disease, shows the influence of the override radiating outwards from a point close to T5 [61].

Evidence of the high use of the override by some unmedicated patients comes from a study of interhemispheric alpha coherence by MorrisonStewart et al. [62]. When the overall data was considered without prior hypotheses, no conclusions could be drawn. Here however T5-T6 can be considered on its own. In an at rest eyes open condition, the standard deviation in the T5-T6 coherence was 1.85 times higher for unmedicated patients than for controls (F=3.43, with 9, 29 degrees of freedom, p<.05 consistent="" with="" some="" patients="" using="" the="" override.="" wp_automatic_readability="174">

Ford et al. and Kam et al. also both found raised coherence in the theta range with P3–P4 or areas close to them, pointing to activity of the cutout. The only task where patients could have become stuck was that of conforming to the instructions. Kam et al. told patients to sit still and keep the eyes closed. Yet a reference electrode was put on the nose. Patients could have become stuck on whether or not to peep. This would mean that the cut-out would be triggered during the recording, consistent with theta being involved. Thus the overall EEG findings are consistent with both cut-out and override being initiated with theta and, at least with the override, low theta is involved.

Metabolism and blood flow evidence

The first five studies that were encountered with evidence of low activity at the cut-out point are as follows.

Hawco et al. [63] studied patients of mean age 24 years, time in treatment 1.4 years, SAPS 10.6, SANS 19. Participants watched a video of a trip through a virtual village where they saw objects beside different people at different places. They were told to pay careful attention to the object, person, and location and to remember them. Later they were scanned while saying which of two objects had been seen with particular people or in particular places. Selecting which objects had been seen in particular places was associated with low activity at – 2 – 60 36, converted from Montreal Neurological Institute coordinates (MNI). This is assumed to be the cut-out point because of its closeness to previous observations of the location of the point. There was no similar finding with selecting which object had been seen with a particular person. However in both conditions the patients had low activity in the parietal lobe, which also points to the cut-out being active.

Harvey et al. [64] used chronic patients, mean age 42 years, illness duration 21 years, BPRS 40, SANS 27.1. Participants rated the affective state of someone shown on a video. Failure to predict the affective state, as judged by the person on the video, was associated with low activity at – 5 – 65 25, assumed to be the cut-out point, more with patients than with controls. There was no corresponding evidence of suppression of activity in the parietal lobe.

Hashimoto et al. [65] studied patients of mean age 31 years, illness duration 7 years, PANSS 37.4. They used video clips of someone moving about with points of light attached to parts of the body, and called it ‘biological motion’. Points of light moving about in an uncoordinated way were called ‘scrambled motion’. A series of clips was shown and a button had to be pressed when there was a repetition. Cortical activity with biological motion, relative to that with scrambled motion, was low at – 8 – 68 38, converted from MNI, assumed to be the cut-out point, for patients relative to controls. There was corresponding evidence of some suppression of activity in the parietal lobe.

Symptomatic chronic patients, mean age 37 years, duration of illness 14 years, PANSS 80, BPRS 26, were studied by Stephane et al. [66]. In one condition, patients were required to read aloud simple one or two syllable words in large letters from a computer screen. In another they just looked at the screen. In the former condition relative to the latter, patients had low metabolism at – 20 – 65 27, assumed to be the cut-out point. The difference was found only with Cynthias, who would have had the cut-out. There was no corresponding evidence of parietal suppression.

Kambeitz-Ilankovic et al. [67] studied patients of mean age 26 years, duration of illness 1-18 months, and PANSS 29.2. Participants heard a recording of their own voice or that of someone else accompanied by a picture of their own face or that of someone else. They had to indicate whether the voice was their own or not, using a joystick. Patients had lower activation than controls at – 1 – 68 38 when the recording was of a participant’s own voice but the picture was of someone else. There was no corresponding evidence of the parietal lobe being suppressed.

The interpretation of aspects of these studies in terms of the cut-out only provides alternatives to the interpretations already given by their authors. Still they add to the already substantial evidence about the cut-out point. The mean of the coordinates is – 7 – 65 33, close to the mean of previous observations of the cut-out point, – 7 – 67 37.

There is corresponding evidence of parietal suppression with only two of the studies. This could be due to the lack of anything problematic that provokes parietal activity. Thus the cut-out point is a control or signal point. If activity there is low then the cut-out is active and no new work is done on the freedom problem. If activity is high then work can be done on the problem, leading to activity in the left parietal lobe. In any particular study, the task that is set will determine whereabouts in the left parietal lobe that the contrast between the experimental and control groups will be observed. For example if the instructions given to participants are problematic then low activity will be observed in the inferior parietal lobule that deals with language, during the cut-out. If there is nothing that is problematic for participants then the suppression of the parietal lobe cannot be observed.

It must be noted that a patient versus control group difference could arise at the cut-out point because the controls experience a threat to freedom that patients do not. In the study by Kambeitz-Ilankovic et al., for example, the control group could have objected to having their own voice linked with a picture of someone else. As the cut-out point is also the point where metabolism reflects concern about the freedom problem generally, this could mean that the control group had raised metabolism at the cutout point, creating the observed patient versus control group difference.

Several studies that involved tasks and fully reported activity in the cortex did not report low activity at the cut-out point. With some of the tasks it might have been hard to become stuck. Thus Singh et al. [68] used patients with mean age 31 years, illness duration 9 years, SAPS 8.6, SANS 12.6. The task was feeling the emotions generated by photographs of the aftermath of a disaster. Harvey and Lepage [69] used patients with mean age 31 years, illness duration 10 years, SAPS 14.0, SANS 18.7. Some scenes were shown followed by a mixture of them and new ones. The task was to indicate whether the scene had been seen before. There were no instructions that scenes had to be remembered. On the other hand with some tasks that gave no evidence of the cut-out someone might relatively easily have become stuck. Yoon et al. [70] used patients with mean age 20 years, illness duration less than 1 year, BPRS 46.5, SAPS 30, SANS 30. The AX task was used, where a series of letters is shown and a button is pressed when X is preceded by A. Someone might have become stuck in interpreting the instructions. In a study by Siemerkus et al. [71] patients had mean age 26 years, illness duration 5 years, SAPS 2.4, SANS 2.1. The task was to negotiate a virtual maze, and here someone might readily have become stuck.

In all of the studies the patients were medicated. The assessments by the various scales, especially comparing Stephane et al. with Yoon et al. and Siemerkus et al., suggest that the cut-out is easier to trigger when the illness duration is longer and the level of residual symptoms is higher.

Appendix 2

R’s abnormality in the auditory no-ball task

In the active form of this task a button has to be pressed when a repeated sound is unpredictably replaced by a different one. A passive version where people just listen to the sounds is typically studied. In response to the odd sounds both typical people and patients develop a negative potential on the scalp, called the mismatch negativity (MMN). The response can occur when someone is even reading a book [72]. This would take up L’s attention so fully that the effect appears to be attributable to R, in these conditions.

Usually both R and L will contribute to the MMN. R deals with the certainty problem and each odd sound will lower certainty about the environment. R will try to raise expectation of certainty by predicting the odd sounds. Yet if they occur at random then R will fail. It is assumed that the contribution of R to the MMN derives from this failure experience. With patients, Rs will be affected by their involvement with the certaintyfreedom dilemma. They will be primed to expect failure and hence, MMN will occur more quickly. Yet they might be distracted from the new failure, causing the MMN to be less. The contribution from L to the MMN will depend on the sounds being regarded as a puzzle and being given attention. Because of the randomization there will be failure just as with R.

There is evidence of contributions to MMN from both R and L. In a study by Hong et al. [73], participants listened to the sequence of sounds while sitting in a sound proofed room. The MMN of controls was related most to 5-12 Hz, reflecting high theta. This implies that L was involved, exerting influence. The absence of anything but the sequence of sounds might have encouraged controls to regard this as a puzzle that they had to solve. With patients there was almost no sign of MMN being related to high theta. Instead it was related to less than 5 Hz, reflecting low theta, and hence R exerting influence. It is as if patients responded passively, in accord with their passive acceptance of treatments, so that L was inactive. This highlights the influence on L of the attitude differences of patients and controls. An important additional finding was that less than 5 Hz was augmented with patients. This implies that their Rs were abnormally active in the oddball conditions.

Calhoun et al. [74] observed that patients had activity in a particular part of the right temporal lobe, thought to be BA42, during the task, whereas typical people had none. There was no mention of activity on the left. There is BA 42 on both left and right and that on the left is an auditory association area. Hence BA42 on the right might be used by R for thinking in terms of its own nonverbal language. Something that patient’s Rs would do, as they sometimes function non-veridically, is to decide to function veridically. The Rs of controls would not have to do this. Hence it might account for the difference between patients and controls. The patients were in full or partial remission. The discrimination from controls was almost complete and was cross-validated. This additional activity required by the Rs of patients might explain the finding by Hong et al. that less than 5 Hz is augmented.

In an EEG study by Takahashi et al. [75] exact Low Resolution Electromagnetic Tomography Analysis (eLORETA) was used with large samples to detect the brain structures that contribute to MMN. Participants watched a silent video while they listened to the sounds and were told to pay careful attention to the video because they might be asked questions about it. The magnitude of the MMN varied widely between patients, and came largely from the left, as if L’s attention was often not fully taken up by the video. The only reliable differences between patients and controls was in patients having less influence from the right cingulate gyrus, the right paracentral lobule, and especially the right medial central frontal gyrus and surrounding areas. As noted earlier, activity in the left homolog of the latter area reflects willed activity [33]. Hence the reduced activity on the right might reflect a reduced level of involvement by R. This is consistent with the Rs of patients being distracted by the certainty-freedom dilemma and with having to engage in the additional activity described by Calhoun et al.. Still it reflects another abnormality in the functioning of R.

That the latency of the MMN is less for patients is supported by study by Kargel et al. [76], as well as other recent studies that they mention, though not by some older studies.

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