4. The Diagnosed

• Phase Transitions and Psychopathology by James Brody, 2/18/98
  
  

Sally, in her 40s and married to an erratic professional, sat with me in session. She arrived ranting and crying. Alex had, in her mind, shown absolutely no progress in the months that he came to me. He was still a lunken clod. She sobbed for a few moments about his faults, then remarked, "As we were making the bed this morning ...." I struck, mustering all the positive affective display in my evolved nature.

"Wait, I know him well. That guy actually helped you make a bed? You're lying to me! Sure it wasn't someone else?!!" Tears stopped, she giggled.

"Yes! Come to think of it, he also sat through dinner last night, talked to our sons, and drank only 2 beers instead of 4. He gave me a flower and said he loved me." Of course. There had been no changes in him when her mind was phase locked into a negative perception. I pulled her back that morning to the positive side of her narrow "Maybe Range." Of course, a single lesson did not stick, her positive range was no more stable than the negative. I repeated my tactic several more times before she caught onto doing it to herself. I also asked her one more time to apply the cognitive drill I had given her so that she could acquire the skill to pull herself back to Maybe, becoming more durable, resilient, and independent.

Stan, also in his 40s and a construction worker, commented that he has always been an all or none person. Temper and oppositional behavior sometimes lost him access to his wife, his children, and exacerbated poor relations with other people at work. He arrived one day in my office. He had a mild tremor and was slightly tearful because his boss, customarily inept, had sent him several notes about safety infractions. Stan had several allies in the company, none of them immediately available. His worry about his job was correlated with his drinking 5 cans of beer each evening and yelling at his wife and children about the small, stupid things that happen in homes. Our discussion highlighted his allies both at work and at home; he also had professional support from me and from a family attorney. He drafted responses to his supervisor, gained confidence from a union steward, and had his lawyer ask for a copy of the personnel file and related policies. Stan calmed within a few days because the enemy began treating him "nicer." He had won; his friends, his group got him back into his Maybe Range.

These few examples involve relatively average people, nudged into bimodal patterns perhaps by stress, fatigue, or by the failure of their customary strategies for handling dilemmas. However, narrowed phase transitions may also underlie the things we see in a wide range of formal psychiatric entities, including bipolar disorders, ADHD, learning disabilities, schizophrenia, post surgical brain damage, minimal (or maximal) head injury, mental retardation, or Alzheimers. Any disorder that limits not only the number of neurons but also the number of interconnections between them should impose a binary quality on thinking and behavior. All or none transition shifts will be seen that are not proportionate to changes in stimulus (internal or external) conditions. (8)

Analogue feelings and graded behavior intensities often occur with emotional sensations, whether positive or negative; however, the degree of variation, the existence of a trait rather than a state, perhaps tells us something of the nature of the disorder. Binary or episodic events must reflect some problem with interconnections; gradual variations of intensity suggest that parallel processing is intact but the activity of more generalized mechanisms, such as those for arousal, is excessive or deficient. Anxiety, for example, often has a graded quality and has been seen as a precursor state to other disorders. We learn to distinguish between a little fear and ever greater intensities of it. However, experience a head injury, shear axons and lose this delicate modulation. The absence of intensity shifts becomes a pessimistic diagnostic sign, a warning of poorer outcomes. (9)

Binary Anxiety Disorders ... Sally alternated from happiness to anger and back again with small inputs from her mother or her brother. She also had difficulty making or implementing decisions about daily self maintenance, academic, or recreational sequences. 150 mg of St John's Wort eliminated most of her ambivalence. She commented that she could "choose" whether to get upset whereas she could not do so earlier. In her instance, "anxiety" elicited escape routines while taking her out of Maybe where she could generate less extreme options. Psychosomatic children also exhibit puzzling, binary phase shifts. They will retch, complain of stomach pain, and generate diarrhea until told that they can stay home from school. The ensuing gain in their health replays New Testament examples. Other children cry, cling, scream mightily when mom drops them off at day care. Once the little hysteric is inside the building, smiles return. The changes are so rapid that blaming and suspicion regularly occur. "She's faking it!" Probably not so.

Panic, social phobia, and obsessive compulsive disorder (OCD) have a mix of analog and binary characteristics. Fear and avoidance of public situations (social phobia) can have a graded character in its onset and clients can more easily make a proportioned response to it than is likely with either panic or OCD. Clients may have a global difficulty with anxiety, however, much of the problem appears to center within a restricted number of settings such as abandonment, safety, or contamination. People with one type of anxiety disorder may have difficulty with multiple settings, however, many of them seem better described as having more circumscribed fear responses.

OCD appears to be stimulus bound and binary in its expression. A digital character is expected as a matter of definition. That is, there may be sharp differences in anxiety with changes in task and situation. It may be impossible for a person to have OCD about everything that they do. Instead, the situation and behavior content appear highly stereotyped with islands of immobility and many areas of intact, smooth transitions in thought and action. Given the rigid characteristics of OCD routines, it's not surprising that highly anxious people, to the same extent as highly impulsive ones, will have difficulty generating compromises and solutions to social difficulties.

Of course, anxiety interacts with other syndromes. For example, 40% or more of adults with Attention Deficity, Hyperactivity Disorder also have two or more anxiety disorders. Modular or adaptationist models of the mind correctly predict that impulse disorders such as ADHD will not be global but will vary abruptly as a function of setting and task (see below). Kauffman's model might predict that if there is an impulse or "attention problem" in one particular academic subject, other phase transition problems could be more likely. Thus, a restless (because they don't know the material) person in English class is also expected to be more anxious in English rather than in math and more likely to have overwhelming doses of it rather than the milder intensity that can help performance.

Mood shifts ... "Depression" -- all forms of it -- has its links with phase transitions. Small reversals elicit a cessation of cognitive and motor activity. There may not be a sufficient Maybe Range, an area in which we stop, wait, and let competing assemblies settle into a graded response that better matches our context. The thought patterns of distressed people are perhaps an expression of phase locks in sublinguistic assemblies. Beck's gerunds, "awfulizing and catastrophizing," summarize extreme cognitions in a distraught person. (10) Depression may eventually sort into genetic and environmental (reactive) components. Kauffman notes that it is possible to "bias" a decision net towards activity or inhibition by the type of logic elements that are use. "And" and "or" elements tend to build coherence; other types erode it. A genetic predisposition (or an early stress that "tunes" circuits) could establish a preponderance for worry or for inhibition. More reactive forms of depression are triggered by particular events and are easier to treat by a reversal of environmental conditions. Thus, the honored wisdom that premorbid functioning is a significant variable in outcome may have its ties to Kauffman's model.

Bipolar disorder ... Binary decisions and value judgments seem to be more likely with bipolar fluctuations in mood. (11) Rapid cycling becomes understandable as a phase alternation between gloom and elation across too narrow a Maybe Range. The problem of "rapid cycling" after some medications and in some people without the medications, (12) suggests a problem with too little interaction between adjoining neurons, whether a result of deficient anatomy or chemistry. The critical sites for mood regulation, for emotional circumspection, may have too few interconnections between parallel, competing action circuits. Thus, fewer potential patterns of cell activity exist. There is more of an all or none quality about the individual, less exploration of subtle options, and an erosion of the capacity for waiting. However, older adaptations may, although having weaker linguistic dependence, be more robust, more resistent to disruption. Thus, a manic kid can be impulsive in many domains but his social planning, his territorial judgments, his ability to barter may be intact even while he is less tolerant of factional disloyalty.

Manic children can have special problems with narrow phase transitions in regard to contingent relationships. Joey (12 y.o.) exclaimed, "Dr. Brody is my best friend" when confronting his father about a grounding. Joey, certain that it was unfair, enlisted me in his army when I agreed with him. He instantly angered with his mother, who planned to corner dad later, and accused her of betraying him. "You agreed with Dr. Brody and said you would back me." This same child had thoroughly disliked me because I trained his parents to use time out. No more than a millisecond was needed for him to switch his opinion of me when I muttered "Groundings should last an afternoon at the most." Manic adults vascillate wildly because of similar difficulties with subtle and contingent shifts in reciprocal agreements.

"Not listening" ... Attention deficit, hyperactivity disorder (ADHD) is recently theorized not to consistent of an attention problem but rather a failure of response inhibition (Barkley 1997), a motor rather than a sensory problem. Excess impulsiveness is correlated with impairment in Executive Functions, those of task persistence, language processing, mental rehearsal, modulation of affect, problem analysis, and the synthesis of novel routines, . Again, a reduction in the number of interconnections between relevant inhibitory links may underlie the awkwardness that ADHD carries.

Rapid emotional shifts are also seen commonly with ADHD. These children and adults appear to have a narrower Maybe Range and flip rapidly from joy to anger and back again. Its sidekick, Attention Deficit without Hyperactivity (ADD), may rest on a failure of lateral inhibition but in the sensory rather than motor areas. ADD appears to have a sensory distractibility component, perhaps centered in the parietal areas of the brain, ADHD a motor one that involves the frontal, subcortical nuclei. "Attention" can be spastic and phasic in ADD, task persistence likewise in ADHD.

The concept of Psychological Adaptations, in combination with phase transitions describe many puzzling aspects of ADHD. High day-to-day variability in task completion has been accepted by some (e.g., Barkley,1996) as an essential aspect of the disorder. This variability is not surprising if we consider all the environmental factors that may erode a resilient mind set. Further, every ADHD child does NOT exhibit a global problem with sustained attention. There is a powerful interaction with the nature of the task, and likely, the relevant Psychological Adaptation. For example, Cindy is 13 yo and well known to sidetrack in school; however, she displays magnificent attention when watching other children. Luke (14 yo) stared around my office during our interview. I asked him a question but he only tracked the first half of it; Emmy slinked her blue-eyed, white furred body into the room and immediately owned his mind. Jared (42 yo) has significant concentration problems in prolonged conversations and with most paperwork. However, he recently bagged, labeled, and planned planting sites and dates for a thousand plant bulbs that he was given. (13)

Head injury ... Various forms of rigidity and indecision, with phase shifts in moods and more obvious response stereotypy are common. Movement and thought lose their smooth quality, "maybe" becomes elusive. I personally experienced some of these things after my cardiac bypass in 1989. There were 3-6 episodes over a year in which my psychological adaptations for facial recognition were impaired. There was an overwhelming conviction when I saw a stranger but recognized an old friend, walking well inside their personal space, greeting them, starting conversations, and eliciting withdrawal. It was embarrassing; fortunately, a friend was along each time to pull me away, still trying to talk. I "learned" to distrust my people recognition anytime I was absolutely convinced that I knew a person. So long as there was a doubt, I could trust the balance of my judgment and was never wrong. If I was positive that I knew them, then I didn't. There also was no case in which I failed to recognize a friend; all errors involved bogus recognition of strangers.

Schizophrenia ..., There may be an associated not only with fewer neurons but also with fewer interconnections. Schizophrenia was classically noted for the "4 As", exaggerated ambivalence, loosened associations, flattened affect, and autistic features. Sometimes the patient even had difficulty entering a room. He or she stood on the threshold and leaned in but immediately rocked back out. Emotional reactions appeared "inappropriate" because they no longer synchronized with the affective displays of surrounding people, people without an impairment. The usual connections failed between individual words or between sequences of them. All of these features could be related to a decrease in the numbers and types of interconnections between psychological modules.

Autistic rocking, also seen with schizophrenia, might be an expression of a narrow phase transition. There is less gradation of behavior, an alternation that goes indefinitely. For example, Rich has to study in a perfectly upright chair and in silence. He rocks, perhaps to maintain vigilance, and flaps his hands when he is happy. He talks too loudly for most people but talking by other people, music, or traffic noises disrupt his concentration. Yet, he is gifted in remembering people's names, the names of their relatives, the autos they drive, and even numbers of license plates.

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