Introducing Further Developments Towards an ICS Formulation of Psychosis.

A Comment on Gumley, A., White, C.A. & Power, K. (1999) An Interacting Cognitive Subsystems Model of Relapse and the Course of Psychosis. Clinical Psychology and Psychotherapy. 6, 261-279.

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I was particularly interested to read Gumley, White and Power’s article in the October 1999 issue of this journal on "An Interacting Cognitive Subsystems Model of Relapse and the Course of Psychosis" because I have been applying the same model to the conundrum of psychosis, but with a somewhat different emphasis, outlined below.

An exposition of the Interacting Cognitive Subsystems model can be found in the original paper, and of course, in Teasdale and Barnard (1993). In summary, ICS is an information processing model, based on experimental evidence for different forms of coding information; for instance, immediate and sensory based, verbal and logically based, or a more holistic, meaning based coding. These and other distinct codes form the basis for nine postulated subsystems; three are sensory and proprioceptive, two involve higher order pattern recognition; two, the production of response, and two are yet higher order, meaning based systems on which I will now focus, the propositional and the implicational. Memory is integral to each subsystem, and likewise distinguished by separate codes. Thus, the logical, propositional, memory is verbally coded, whereas the implicational memory, that records meaning at a more generic level, is encoded in a rich variety of sensory modalities, and is therefore more immediate and vivid.

Another area illuminated by the research into short term memory and human - computer interaction on which the theory is based (e.g. Barnard 1985) is the need for a transformation process in the interchange of information between one subsystem/coding and another, and that this is constrained by the limitation of the processing capacity. Thus connections are made more immediately within a particular memory store than between the data stored in different memory stores and coded differently. An example of this that will be important for the argument that follows is the rapid connection made between events of personal significance stored in the implicational memory. The other feature of the system that is central to the current argument is the immediate connection between the implicational and body state subsystems, and the much more indirect route by which information about arousal reaches the propositional subsystem. Good functioning in a human being is characterised by ease of communication between propositional and implicational levels, but in certain circumstances, highly charged emotional material can overwhelm the implicational subsystem, leading to avoidance, experienced as various forms of psychopathology or deviance, and disrupting this communication between the subsystems.

I welcome Gumley et al.’s argument that the ICS model holds considerable potential for a fuller understanding of the process of psychotic breakdown and psychotic relapse. I agree that the correspondence between the preoccupations of the implicational subsystem with information pertaining to the self and threats to self concept is mirrored in characteristic delusional material, and the subject matter of auditory hallucinations. Many studies, such as Chadwick and Birchwood (1994) and Kinderman (1994), to name but two, bear this out. I also agree that the interaction between propositional and implicational subsystems, Teasdale and Barnard’s "central engine of cognition" is critical to understanding psychosis, and that relapse is accelerated by the matching of current stimuli with the previous experience of psychosis, stored in implicational memory, because of the saliency given to implicational meaning structures.

However, I would further argue that the ICS model provides the foundation for a fuller understanding of the process of psychotic breakdown and relapse than is presented by Gumley et al. They hypothesise that the destabilisation represented by psychosis can be traced to the effort to reduce irreducable discrepancies between the subsystems, as understood within ICS, but do not bring out the role played by variable arousal states in relations between the subsystems. One of the great strengths of the ICS model is the place accorded to arousal states within information processing. Body state information is fed directly into the implicational level, by-passing the propositional level, which therefore accesses such information indirectly. Neuropsychologically based models of emotion as specialised response systems that operate outside conscious awareness (e.g. see Ledoux 1998,) bear out this indirect relationship between the propositional and implicational levels. Ledoux further tracks the way in which, at states of high arousal, deeper brain structures hold sway, and appraisal becomes restricted to threat relevant material, and access to wider cortical connections becomes restricted (op.cit. 284-5).

The discrepancies between subsystems cited by Gumley et al. will be experienced as threats to the self, and will therefore activate the person’s emotional response system to threat, involving body state arousal and implicational subsystem. The role of anxiety, and therefore, arousal in presence of psychotic symptoms is starting to be more generally recognised. Morrison (1998) looks at the role of arousal, triggered by negative attribution, in maintaining symptoms, and cites Allen & Argus, (1968) and Cooklin, Sturgeon & Leff, (1983) as studies linking psychophysiological arousal with onset of hallucinatory episodes. Tarrier and Turpin (1992) describe the role of arousal in relapse using psychophysiological data. Taken together, this evidence for the role of malfunction in the smooth communication between propositional and implicational level has the potential to elucidate the phenomenon of psychosis at a more fundamental level, by providing a well founded psychological explanation for the difference in quality between psychotic and everyday experience and thought.

This argument focuses attention on the discontinuity in quality of experience between normal and psychotic functioning, which has not been given prominence in recent psychological formulations of psychosis. It introduces the idea that there is variable access to a looser, less logically focused way of operating, which is physically mediated. Though highlighting discontinuity, this argument builds upon, rather than contradicts, the recognition of the continuity between psychotic and everyday thinking on which cognitive behaviour therapy for psychosis is built (see Bentall 1990 e.g.)

ICS helps us to understand the discontinuity in the following manner. The free interchange between implicational and propositional levels, with access to current sensory and other information is the ICS model of health. Schemata are stereotyped patterns of this interchange which are triggered and reinforced on the perception of threat, and consequent high autonomic arousal. Activation of schemata restricts access to new information and true propositional appraisal. I suggest that psychosis represents an instability in the system, in association with variation in arousal levels, which, for longer or shorter time periods, makes new propositional appraisal unreachable.

 

Loss of reliable appraisal of data via the propositional subsystem means loss of ability to distinguish internal and external stimuli, and the dominance of implicational level, schematic, material, with no means of reality testing it. This is in line with the hypotheses exhaustively investigated by Frith (1992) and perhaps makes anomolous experiences more explicable, as well as catastrophic beliefs about them (Chadwick and Birchwood 1994). According to this hypothesis, delusion formation can be understood in terms of the efforts of less adapted cognitive subsystems at meaning making.

The connection with level of arousal links this argument with the Schizotypy school of thinking (Claridge 1997 and 2000) which sees variable thresholds to alteration of state of consciousness as one dimension of variability of personality. According to this body of research, high schizotypy has its basis in brain and neurotransmitter variability, and can lead to greater proneness to catastrophic psychotic breakdown where sufficient environmental stressors are also present. However, they also present evidence, that, as with every personality trait, high schizotypy has beneficial as well as deleterious possibilities, such as creativity, (McCreery in Claridge (1997), and openess to spiritual experience (Jackson 1991).

 

To integrate these arguments with the thesis of Gumley’s paper, the person at risk of psychotic breakdown who remembers previous breakdown as a threat experience (both because it was intrinsically unpleasant and frightening, and because of its aversive consequences in terms of involuntary hospitalisaion and interference with major life goals) will indeed be at risk of entering a vicious circle of fear, leading to breakdown of synchronous communication between propositional and implicational levels, leading more rapidly to psychotic breakdown. The discontinuity argument suggests that, as a background to this "accelerator" process, an individual who has already had one psychotic breakdown is high in schizotypy, and theferore more easily tips over the threshold between operating with a fully functional "central engine of cognition" (i.e. good propositional and implicational levels communication) into desynchrony, and reliance on implicational level functioning.

Another aspect of relapse in psychosis which is illuminated by this perspective, is the positive attraction of psychotic functioning. While much non compliance with medication can be explained by unacceptable side effects, loss of voices and a quality of experience that was valued can be another factor. The option of escape from a reality which offers the individual with mental health problems a place at the bottom of the hierarchy could be another attraction.

The idea that psychotic experience might be chosen and seen as desirable, links well with research coming out of the schizotypy paradigm that extends the idea of the "other side" of the discontinuity form psychotic to spiritual experience and examines the overlap between the two. This is a new area for research, opened up by Jackson in his PhD thesis (Jackson 1991), further developed in Jackson (1997), Jackson & Fulford (1997) and Jackson (2000), and now being pursued by a number of researchers. Jackson compared a sample representative of the general population, but scoring highly on an index of anomolous and spiritual experiences with a clinical sample diagnosed as psychotic, on the same measures, and found considerable overlap. Peters et al(1999) investigated adherants to New Religious Movements, and compared their beliefs with those reported by people diagnosed as suffering from delusions. She found them not distinguishable by content, but only by preoccupation and accompanying distress. Taken together, these findings suggest that the mode of operation discussed above, where the connection between implicational and propositional level is loosened, and the implicational level dominates information processing, could lead to a more general area of human experience than simply psychosis. It could also underlie the area of experience reported as mystical or spiritual. Drug induced states could also be bracketed in this category.

The ICS formulation is helpful in further elucidating this position. Clearly there is a difference between benign spiritual and persecutory psychotic experience, as well as the area of overlap researched by Jackson (op.cit.), Peters (2000) and others. The ease of regaining contact with the propositional level could be the crucial variable here. Propositional level processing is characterised by fine-grained discriminations and thinking in terms of constructs and boundaries. Implicational level processing takes in the whole; concentrates on personal significance, and is not focussed on distinctions. Brief exposure to a sense of unity with the whole, sometimes accompanied by a loss of a sense of individual self, sometimes by an enhancement of such a sense, which characterises mystical/spiritual experience, can be exhilerating and life enhancing. Longer exposure to the same absence of familiar boundaries and landmarks could easily be experienced as persecutory. Loss of a sense of the boundaries of the self could be a way of understanding the common psychotic symptoms of thought insertion and thought broadcast. The characteristic implicational level sense of portentious meaning could become transferred to irrelevant stimuli - so explaining the uncanny personal significance of things like number plates for some sufferers from psychosis. Where contact with propositional level functioning is regained after a short interval, none of these aberrations of information processing characteristic of psychosis, to give but a few examples, need occur.

To return to Gumley et al’s argument, discrepant and disturbing information about the self could well play the crucial role in loosening the connection between the ICS subsystems, and so making way for the anomolous experiences of either initial psychotic breakdown or relapse. Such a formulation accords well with that developed by Jackson (1997) who suggests that psychosis intervenes as a way out of an irresolvable information processing dilemma, which he characterises as "problem solving".

 

 

I am aware that much of what I am here suggesting is speculative,and ripe for investigation. I suggest that such investigation is a worthwhile enterprise, both because of the explanatory power that this formulation brings to otherwise puzzling anomolous experiences, but also because of the new normalising continuum for psychosis that it offers. Without in any way contradicting the generally accepted neurotransmitter function concomitant to psychotic experience, or the distress that it characteristically brings, it links a devalued and stigmatised group to a highly valued area of human experience - the spiritual and mystical. Peter Chadwick’s writings have brought to general attention the mystical aspect that sometimes accompanies psychotic experience ( see Chadwick, 1992, 1997 and 2000 ) which accords with reports gathered in the author’s clinical experience. Recognition of the two possible types of information processing, which the ICS model helps to make clearer and more comprehensible, has potential to be useful in clinical practice and future research into psychosis. A fuller exposition of this point of view is found in Clarke 2000.

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