INTRUSIVE OPPOSITE EMOTIONAL THINKING IN A CHRONIC
"SCHIZO-AFFECTIVE" WOMAN.
A STABILIZED INVERSE HALF-BRAIN
DOMINANCE
OF A SPECIFIC FUNCTION?
Renato
COCCHI MD, a neurologist and a medical psychologist
Summary
The case of a right-handed 42 yrs old woman, prevoiusly
diagnosed as suffering from schizo-affective
psychosis and taking 40 mg daily zuclopentixol, is
presented. Her illness lasted ten years. She was hearing voices, which accused
her as having cast spells. So, she spent her life by praying and expiating
without any relief of her distress. These voices had all the features of
hearing hallucinations, and she was partly aware of it, but she added to them
feelings of guilty, prosecutory thoughts, and depression. Often
in a day, her emotional thoughts were the full opposites of what she felt. She
appeared unable to control these intrusive and emotionally negative thoughts.
The explanation suggested refers to disruption of the suppressing
mechanism of the opposite engram, and to stabilized
opposite half-brain dominance for emotional thinking, dealing with the
compulsory emerging of negative thoughts.
Key
words: intrusive thinking; compulsory negative thoughts; defective
brain dominance; engram; suppression mechanism.
In 1994 I wrote a speculative paper on
defective hemispheric dominance and cognitive behaviour (Cocchi,
1994). In it I put forward the idea that several incongruous behaviours, both
normal and pathological, may be due to defective half-brain dominance. I
asserted that this could have been a temporary, stable or stabilized state. To
give support to this view, I recalled many data, several of which derived from
common evidence.
From neurology I pointed out mirror writing, reading and speaking in brain
injured people, and the mirror focus in epilepsy. The "no" stage in
infancy, opposition and a higher incidence of left-handed among mentally
defective or brain damaged children, come from child neuro-psychiatry. The same
is for contrariness in adolescent age. Psychology gave me the so-called
"janusian" thinking, the use of paradoxical orders in psychotherapy,
and data derived from digit spans and Raven's Coloured Matrices in alcoholics,
demented or college students. The "contrary Mary" came out from the
folklore. Finally adult psychiatry contributed with negativism in certain
psychoses and with the "dissociate" behaviour of drug addicts.
A curious case seen in an outpatients' service added another support to
this view and dealt me to modify my approach to some psychiatric troubles. I
thought it could deserve some interest to many other people so I decided to
refer it broadly.
The case history
On 27 December
First symptoms arose in 1982 after some rumours on her social life, a
fact that became prevailing in her thoughts. With a "pendolino" (a
little pendulum used to divine) she tried to know the persons who were speaking
ill of herself. Her nervous control subsided and one day with this tool she
damned all those malevolent people. Being some mishaps gone on to several of
them, she had feelings of guilt, low self-esteem, lack of interest, and
anxiety.
Treated by antidepressants and anxiolytics with fairly good results, she
kept at her job, although with many troubles due to seasonal relapses.
In January 1987 she had what a psychiatrist reported as an overt
psychotic breakdown. She woke up during the night with great psychomotor
agitation, altered consciousness, delusional magical thoughts, acoustic
hallucinations referred to the above floor. From this, the home of another
family, she heard voices that were making her guilty of curses, which she felt
herself liable for.
After 3-4 weeks of heavy neuroleptic therapy she had partial recovery,
but hallucinations, feelings of guilty, prosecutory thoughts, and depression
did not fully disappear. Therapy did not ask hospital entry. The depressive
episode following lasted about two years, when she did not stop her nursing
work, but at home she did not make anything as housewife. Even their sons did
not get the usual care a mother normally gives to them.
From 1989 to 1994 she had drug therapy and psychotherapy by one
psychiatrist who made the diagnosis of chronic "schizo-affective
psychosis" with episodic relapses.
The drugs she had mainly taken were neuroleptics, antidepressants and
benzodiazepines. Although drug therapies made the narrow down of acute
symptoms, the relapses did not stop. So, she turned out on job, social life,
family and self-caring worsening, with a doubtful and distrustful behaviour.
Acoustic hallucinations had always poor criticism, but she did not leave her
home for the hospital even during relapses.
The last psychiatrist seen prescribed her 10+10+20 mg daily
zuclopentixol and she was usually taking this drug with great compliance.
First consultation
From the record taken during the visit, I refer now the symptoms I
checked.
She says she is suffering since ten years, because she is hearing
voices, which accuse her as having cast spells.
So, she spends her life by praying and expiating without any relief of
her distress. These voices have all the features of hearing hallucinations, and
she is partly aware of it, but she maintains that somebody knows her life,
perhaps her next-door neighbour.
Her son had a nervous breakdown some years ago, and she charges herself
of it, having thought to wish him ill. Of course, she loves her son but
sometimes she seems unable to think right when bad thoughts are coming to her
mind more easily.
Such a fact makes her without any hope.
No difficulties arose in pointing out depressive symptoms and
complaints. I tried the "Name the opposite of the red" Test,
according what I previously wrote on it (Cocchi, 1994). I expected to hear a
response of black, as the colour usually replied by depressed people. Instead
of it, she soon said "white," a colour that let me surprised for many
seconds up to I realized being the white the opposite colour of the black.
It was the second or the third time I heard it in few years of asking,
but only now it assumed a significant meaning. In past I thought the white only
as a very luminescent colour, and I could not link this reply to the
psychiatric state of the person who said it.
Specially asked on that topic, she told that it happens to her to think
dirty words or even oaths, which give her to be more guilty. She does not make
of why such thoughts, so contrary to her habits or religious belief, come to her
mind.
"My head is always working, like a mill, and I feel I cannot ever
direct the course of my thinking," she told.
Neurovegetative symptoms checked were: normal sleeping, a low threshold
for hot, a liking for sweets and meat or cube broth, worsening in autumn. Often
she used to count things without any need to do it. When schooling, she went
better on mathematics than on humanities.
Having asked her attention to this point, she admitted that, often in a
day, her thoughts are the full opposites of what she feels. Therefore, lacking
another way to explain, she interpreted someone made her bewitched, and spent
much time daily in the church by asking God's help to stop it. But what is the
worse, the more she is praying, and even worse thoughts come to her mind soon
after she ended praying.
The neighbour, a person she identifies as a wizard, can read these
thoughts from his mind. He tells them to others, which become aware of her
planning bad things or damning someone.
Thus the diagnosis made at the end of this consultation swung from
neurosis to psychosis, the first being a reduction but the latter perhaps an
exaggeration.
Discussion
At a glance, no troubles arise to classify this psychiatric illness, and
the frame more fitting it seems exactly that of the schizo-affective disorder.
According to DSM-IV, F25.1, the presence of longstanding depressed mood,
hallucinations and delusion is undoubted (diagnostic criteria A, B, C).
No problems also arise when we have to exclude them as consequences of
physiological effects of a substance or a general medical condition (criterion
D).
Although the parallel between this case and the frame of reference is
fairly well shaped, something seems to have not found its room.
If we accept this frame of reference, we face a psychosis with many
remissions, and nobody could easily get away from this diagnosis. However we
can ask ourselves if we should label it as Depressive Disturb not otherwise
specified, DSM-IV, F32.9. From this latter, item 5 points out a Major
Depressive Episode that overlaps a delusional disturb, or a psychotic disturb
NOS, or an active stage of schizophrenia.
This other labelling could imply a different guideline for drug
treatment, in the first case made mainly by antipsychotics, but in the second
one mainly by antidepressants.
This does not appear the same, either for the psychiatrist as well for
the patient. The case history could help us to solve this doubt, if any.
Despite the previous psychiatrists have balanced themselves from
psychosis to depression, as drugs prescribed show, the illness came out as a
truly depressive state. In this stage the so called "magical thought"
and the use of "pendolino" were only a quite normal way of thinking
that belongs to the patient's culture level.
On the other hand, apart perhaps from true psychotic episodes, the woman
always said of a painful awareness of something strange and extraneous in their
thoughts. Her efforts to redirect thinking, though without any success, spoke
for only a partial disruption of the self. Moreover, no psychotic episode
needed an entry in hospital, a fact that seems to deny a true psychosis.
For this reasons I maintain that she had more than a neurosis and maybe
less than a psychosis, but I cannot set out another frame of reference.
Although it is already unusual though debatable case, another feature of
it deserves greater interest. If we watch out on the content of her thoughts,
we can find the singular aspect of them. At least part of emotional thinking
arose reversed on the contrary, and so love becomes hatred.
I need to fully point up what I reported to outline this special
feature.
" Her son had a nervous breakdown some years ago, and she charges
herself of it, having thought to wish him ill. Of course, she loves her son but
sometimes she seems unable to think right when bad thoughts are coming to her
mind more easily."
" ... she told that it happens to her to think dirty words or even
oaths, which give her to be more guilty. She does not make of why such
thoughts, so contrary to her habits or religious belief, come to her
mind."
" Having asked her attention to this point, she admitted that,
often in a day, her thoughts are the full opposites of what she feels."
" But what is the worse, the more she is praying, and even worse
thoughts come to her mind soon after she ended praying."
As I reported above, at the "Name the opposite of the red"
Test, she said "white" instead of the expected answer of black,
usually given by depressed people (*). In facts white is the opposite colour of
the black, and our culture has connoted this latter colour by emotional
negative contents.
As I wrote above, we have to note the presence of compulsory opposite
emotional thinking of intrusive type. There is a half-brain asymmetry for
emotions, being the right hemisphere where negative emotions surely have more
place. (Wittling e Roschman, 1993; Schiff & Lamon, 1994; Schiff &
Gagliese, 1994). As for positive emotions, there is a long-term debate, some
researchers asserting the superiority of left half-brain (Sackeim et al., 1982,
Coffey, 1987; Davidson & Tomarken, 1989; Davidson et al., 1990; Schiff
& Lamon, 1994). From this we can only infer that right half-brain of that
patient is heavily invol-ved in this abnormal verbal behaviour, having her
compulsory thoughts very negative emotional contents.
What seems more difficult to explain is the way this patient elicits the
opposite thinking. We can remember what happens in some neuropathological
conditions.
When subjects have suffered from a cerebral insult, often an ictus, but
also as the result of an accidental trauma or neurosurgery, mirror actions can
appear.
We can see mirror writing and/or reading (Critchley 1928; Paradowski and
Ginzberg, 1971; Streifler and Hofman, 1976, Fisher, Liberman and Shankweiler,
1978; Heilman, Howell, Valenstein and Rothi, 1980; Tankle and Heilman, 1982;
Feinberg and Jones, 1985 ) or even mirror speaking (1st case described by
Cocchi et al., 1986). Mirror behaviours are opposites, at least space
opposites.
There is an explanation supported also through animal research (Orton,
1928; Noble, 1968; Bradshaw, Nettleton and Patterson, 1973). Perceptive
stimuli, usually visual, produce both an engram and its opposite in the two
half-brains in the same time. Normally the brain suppresses the opposite, which
has its place
in the non-dominant hemisphere. Under particular conditions this
suppressing mechanism becomes inhibited, and so the opposite shows itself as a
mirror image. Not only writing, reading and language can take on this mirror-like
behaviour, but the handling of objects can become reversed too (Feinberg &
Jones, 1985).
These last researchers suggest that left-right orientation be not a
unitary characteristic. They maintain it can have a link to differential
activation of the cerebral hemispheres, when carrying out motor or other types
of tasks. The presence of mirror writing or mirror speaking witnesses double
engrams also for internal stimuli, as it happened in this woman.
Now the more likely hypothesis is that negative thinking of emotional
type comes out from stabilized inverse half-brain dominance, with their
opposite engrams. Of course, this fact could not necessarily involve the whole
non-dominant half-brain, in our case the right half-brain, but only a
particular function of it. I cannot exclude that this function's salience was
growing on the functional depression of an opposite one located in the other
hemisphere, but I lack information about a similar event. For this woman, the
more she searched for right emotional thinking by praying, the worse thoughts
blew up, after she had stopped intentional thinking.
If the hypothesis of left half-brain superiority for positive emotions
were true, we should have two ways to explain our case. The first one refers to
the depression of left half-brain dominance for emotional thinking, but the
second one postulates the exaltation of right half-brain dominance for it.
The normal suppressing mechanism avoiding the clear awareness of the
opposite seems become unable to work for this kind of thoughts. Nevertheless,
we have not the co-presence of two opposites as it happens in
"janusian" thinking (Rothenberg 1973, 1982), but the unwanted
salience of negative thoughts.
Conclusion
This is parhaps a pioneer paper with in detail report of a singular case
of a woman aware but unable to control her intrusive emotionally negative
thoughts.
The explanation suggested refers to disruption of the suppressing
mechanism of the opposite engram, and to stabilized opposite half-brain
dominance for emotional thinking, dealing with the compulsory emerging of
negative bad thoughts. As neuropsychology grows, many of what in past we have
assumed as delusions without any biological basis, will find their solutions.
As a common feature, I suppose they could rely on hyper- or hypofunction of
special brain abilities whose presence becomes evident when they start
dysfunctioning.
(*) When I was ending this paper, an ophthalmologist physician came to
consultation for neurotic depressive symptoms. At "Name the opposite of
the red" Test he answered "white" after a short while, although
he was ordered to answer without any hesitation. I questioned him if white had
been the first colour that had come to his mind. He said that the first one was
black, and white followed. He just appeared another person with troubles in
suppressing the opposite engram. To ascertain it, I asked after opposite
behaviours in his daily life, and he admitted that those were his main problem.
Often he did the opposite of what he first thought. In this physician the
co-presence of the opposite was usually emerging in a strong way, driving him
to contradictory behaviours. His wife, who was present to the consultation,
confirmed the fact. This opposite did not involve only emotional thinking.
Aknowledgements
This research was supported by a generous grant of the Mondaini family,
of Scafa (Pescara) in memoriam of their daughter Manuela.
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Author's address: dr Renato COCCHI, via Rabbeno, 3
42100 Reggio Emilia (Italy)
renatococchi@libero.it
Speculation and theoretical bases