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The Identity of Schizophrenia: A multilevel systems approachNicholas C. Paritsisab

a Laboratory of Cybernetics and Behavioural Systems Science, Department of Psychiatry andBehavioural Sciences, School of Health Sciences, Division of Medicine, University of Crete, Stavrakia,Heraklion, Crete, Greece b International Systems Institute, Carmel, CA, USA

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The Identity of Schizophrenia:A Multilevel Systems Approach

NICHOLAS C. PARITSIS

Laboratory of Cybernetics and Behavioural Systems Science, Department of Psychiatryand Behavioural Sciences, School of Health Sciences, Division of Medicine, University ofCrete, Stavrakia, Heraklion, Crete, Greece, and International Systems Institute, 25781Morse Drive, Carmel, CA 92923, USA

(Received May 30, 1994)

ABSTRACT: The position is taken that for the identification of natural systems, thedescription at many levels of systems hierarchical organization is essential. Otherwise, therepresentation of the phenomena is limited and possibly misleading. This position specifiedthe strategy that was followed for the presentation of the identity of schizophrenia. The basiccharacteristics of schizophrenia are presented at the molecular, anatomical and neuro-physiological, psychological and phenomenological, at the family, and at the socioculturallevels. Only well established empirical findings are presented. The interpretation of thesefindings including the various theories on schizophrenia are not mentioned. For the purposeof bringing some order and of reducing the complexity of the multilevel description, anattempt is made to outline a model of the basic components of schizophrenia. A number ofinterrelated components, that exist at many levels of systems hierarchical organization, aregrouped in three dimensions or factors.

KEYWORDS: multilevel analysis, holons, schizophrenia, systems identity

INTRODUCTION

Koestler (1967) viewed living systems as consisting of "holons," where they arecomponents of higher systems while consisting of lower parts themselves, thusbehaving as both a whole and as a part of a system. For example, a human consistsof cells, which consist of molecules, and so on. Besides, this human being couldbelong to a family and this family to belong to a society. Laszlo (1972), similarly,described natural systems as been organized in successive levels of hierarchicalorganization.

Systems can be regarded as an abstraction of reality. The abstract description ofreality that cybernetics and systems offer enables the understanding of the func-tioning of the system independent of the material from which the system isconstructed (Ashby 1958). This abstraction does not hinder the study of the variouslevels of hierarchical systems organization, since at each level the holons may haveadditional specific abstract properties, depending on the defined elements andtheir relations.

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108 NICHOLAS C. PARITSIS

According to Koestler (1967) the emergent properties of a holon are determinedby the environment of this holon and the structural configuration of itself. Laszlo(1972) contends that the constraints imposed by the system as a whole through itshierarchical structure induces the emergent properties of its parts.

Paritsis (1989) contends that the relationships among the elements determine theproperties of the elements and of the whole, and vice versa the properties of theparts and of the whole determine the relations of the parts. Furthermore andsimilarly, among systems constructed by the same type of elements, a differentorder at the lower level produces emergent variety at the higher level (Paritsis,1993). This variety can be considered as a way to create the variation of species putforward by Darwin (1856).

A number of authors used the simultaneous analysis and/or intervention at manylevels of systems hierarchical organization. Minuchin (1980) introduced the ecolog-ical systems approach for the therapy of the child. This approach extends theintervention in all the systems the child is a member of, e.g. the family, the peer'sgroup, the class group members together with their teacher. Adolfi et al. (1978) usedthis approach successfully for reducing behavioral problems of children at school.Paritsis (1983,1987,1989) developed a general systems' approach considering thatfor all natural systems analysis and intervention it is important to consider at leastthree levels of living systems hierarchical organization. In particular, the higherand the lower level have to be considered besides the level in which the emphasis isgiven. In the case of systems analysis for both obtaining a more enriched, complete,and realistic picture (Paritsis, 1983, 1993). In the case of intervention because theintervention at one level influences the upper and lower levels, and hence the morelevels of intervention are used, the more effective the intervention is (Paritsis, 1987,1989).

Systems science has as a cornerstone of its methodology the important role of therelationships that determine to a large extent the properties of the whole system.An implication of this way of thinking is that the context in which a phenomenontakes place is important, since the relation of the system under analysis with its"environment" influences the properties and the functioning of the system. Sim-ilarly, each successive level of analysis influences its neighbor in the rank. Hence, themulti-level analysis is a direct implication of core ideas of systems thinking.

The identity of schizophrenia has been perceived differently through history.Ancient Greeks and in particular Hippocrates, described it as a disease under thename "irapa(J>poowii" or "irapaKoirT)" (cutting the mind at inappropriate parts).The Hippocratic school took into account both the organism and the environment(physical and social) and the history of patient for all diseases including the mentalones. This reflected on the method of treatment in the A<TK\TimeCo (the equivalentof a hospital at that time) ; diseases including the mental diseases were believed to berelated with the circulation of inappropriate chemicals (hymos) in the body. Thusthe treatment included appropriate drugs, psychological therapy, exercise, leisureand cultural activities.

In Roman times, mental disease was considered to be due to the unethical andamoral behavior of the person leading to his punishment by the gods that inflictedthe disease as a method of punishment. The treatment, then, included religious


THE IDENTITY OF SCHIZOPHRENIA 109

rituals and methods of learning the right way of behavior, such as teaching,discussions, and, mainly, various punishments.

During medieval times in western Europe, following the influence of the Romantradition and of the Catholic church, it was believed that madness (the equivalent ofschizophrenia) was a consequence of the occupation of the mind by the devil. Thetreatment included various punishments, while, in the difficult cases the "treat-ment" was the execution of the patient, by burning him alive, after the decisionof the Holy Inquisition.

In the Byzantine empire, mental disease was considered to be related to theinappropriate chemicals and the influence of the environment. Treatment tookplace in the hospitals of the time, and drugs were also used.

Emil Kraepelin (1896) first scientifically described schizophrenia as a diseaseentity under the term dementia praecox; a term introduced by Morel who was acontemporary of Kraepelin. According to Kraepelin, the basic characteristic ofdementia praecox was the gradual mental deterioration of the patient. Bleuler(1911) introduced the term schizophrenia, which has the meaning of the splitting(Greek: crxiÇo = schizo) of the mental apparatus (Greek: (f>peva = phrena). Finally,Schneider (1957) introduced the first rank symptoms of schizophrenia, whichincluded specific hallucinations, delusions and distorted mechanisms of thought.

The purpose of this paper is first to present a multilevel description of the basiccharacteristics of schizophrenia, by starting from the molecular level, and endingat the cultural level of systems hierarchical organization. Then on the basis of thismultilevel description at the concrete level, an outline of a more abstract model ofthe basic components of schizophrenia will be presented.

CHARACTERISTICS OF SCHIZOPHRENIA AT MANY LEVELS OF SYSTEMSHIERARCHICAL ORGANIZATION

The description of the characteristics of schizophrenia will neither be exhaustivenor complete. However there will be an attempt to mention the most importantcharacteristics at each level, leaving out the theories and concentrating on empiricalfindings.

Molecular Genetics and Psychopharmacology

The attempt to identify a locus in the chromosomes that is related to schizo-phrenia has failed so far. The hopes developed at a time (e.g., Sherrington et al.,1988) evaporated very soon after the publication of contradictory results (e.g., StClaire et al., 1989). This attempt, however, continues, since there is accumulatedevidence that there is a strong element of heredity in schizophrenia (see Crow,1991). This evidence comes from family studies (e.g., Gottesman and Shields, 1982),twin studies (e.g., Shields and Slater, 1967) and adoption studies. For example,research on adopted children raised by non schizophrenic step parents, shown thatthe biological relatives of schizophrenic children had about 5 times more of a



schizophreniclike diagnosis than the biological relatives of nonschizophrenic chil-dren (Kety et ai, 1971).

At the molecular level another very important issue concerns the connectivity ofthe neural network of the brain. Neurotransmitters, that realize the communicationbetween neurones, can control or modify this connectivity. Each neurone releasesneurotransmitters that form the output of this neurone and at the same time actas the input to another neurone. The later, receives the so-formed input throughreceptors that are specific for each neurotransmitter.

Psychotropic drugs, namely drugs that modify the behavior of the patientinfluence the function of neurotransmitters, by changing, in various ways, theproduction, the release, the reception or, in general, the presence of neurotransmit-ters as an input.

Most of the chemical substances with primarily anti psychotic activity, have as acommon feature the inhibition of the transmission of the neurotransmitter dopa-mine (Kendel, 1988). Hence, there is an association of dopamine with schizo-phrenia. However, the mechanism of the involvement of dopamine in the onset andprogress of schizophrenia is not yet known. Neurones that communicate throughthis neurotransmitter are found in some areas including the limbic system thatembodies largely the processing of primary emotions such as desires, fears andaggressivity.

Furthermore, benzodiazepines, which are drugs with anxiolytic properties, whenadministered in higher than the anxiolytic doses show substantial anti-psychoticeffect, comparable with that of anti-psychotic drugs (e.g., Nestoros et al., 1983). Themain influence of these drugs on neurotransmission activity is the enhancement ofthe inhibitory effect that the neurotransmitter GABA (gamma-aminobutyric acid)exerts on neurones (e.g., Vellucci, 1989). This neurotransmitter is found, amongother places, in the thalamus where emotional and cognitive functions, related tothe incoming information into the brain, are realized. GABA is also found in thecortex where the higher mental processes are realized.

Anatomy and Neurophysiology

There is a great amount of studies considering the brain structure and functionof schizophrenics. However, the majority of these studies did not show the desirableconsistency in their findings. For this reason only findings with considerable consis-tency are going to be mentioned here.

The skulls of schizophrenic patients were found to be of rhomboid shape(Galimov 1979), or otherwise wider and lower (Paritsis et al., 1982). The mainanatomical findings from post-mortem studies in the brains of schizophrenicpatients, are the neuronal abnormalities and atrophy of frontal cortical areas (seeKirch and Weinberger, 1986), and the larger corpus callosum (Rosenthal andBigelow, 1972). In studies using X-ray computerized tomography cortical atrophy(ventricular enlargement and widened cortical fissures and sulci) especially appar-ent in prefrontal areas (Shelton and Weinberger, 1986) was shown to be present inschizophrenic patients. Similarly the results from positron emission tomographystudies showed lower frontal metabolic rates in the brains of schizophrenic patients,



both at rest (Weinberger and Berman, 1988) and during cognitive tasks (Cohenet al, 1987).

In electroencephalographic studies the most consistent finding is the abnor-malities in the temporal lobe (e.g., Abrams and Taylor, 1980; Michelogianis et al.,1991). Schizophrenics are also less able to activate the left anterior regions of thebrain during activation tasks (Morrison-Stewart et al, 1991).

Psychology and Cognition

Schizophrenic patients, in psycho-physiological research do not show habitua-tion to galvanic skin stimulation (Mednick, 1970) and tend to be distracted byirrelevant aspects in the context of a stimulus (Shakow, 1963). These findings agree wellwith the disorder of attention found in schizophrenic patients (Chapman, 1966).

Another important characteristic of schizophrenic thought is the "overinclusive-ness," namely, a property of the schizophrenic cognitive function to include at thesame category irrelevant concepts (Cameron, 1938; Payne, 1962).

The logic of schizophrenics is also very disturbed. One type of disturbance is theprimitive thinking (Storch, 1924). Arieti (1978) describes it as a "paleologic" type ofthinking according to which, an entity (A) can also be another entity (B), with theonly and sufficient condition that both have at least one feature in common, or theybelong to the same category. Levin (1938) compares this type of schizophrenicthought with that of young children.

Schneider (1959) described the "illogical thinking" as another type of distur-bance, which he included in the First Rank symptoms characterizing schizo-phrenia. Especially, illogical thinking is a disturbance of the process of inference,during which there are logical gaps (and jumps) leading to arbitrary and inappro-priate conclusions. This is similar to what Cameron has called "asyndetic thinking."Arieti (1978) classifies the narrower conception of time into a special type ofschizophrenic, or autistic thought and as a form of primitive thinking. In particular,Balken (1943) found that in Thematic Apprehension Test, the schizophrenics havegreater difficulty distinguishing between past, present and future. Schizophrenicshave also a difficulty for abstract thinking and they have a predisposition forconcrete thinking (Hamilton, 1976). The syntactic structure of schizophrenicspeech is also different from normal controls (Morice and Ingram, 1982).

Phenomenology and Symptomatology

The definition and description of schizophrenia at the clinical level of symp-tomatology has changed—and still is—over time, with country and school ofthought. For this reason, the classification given in the 10th revision of the Interna-tional Classification of Diseases, Mental Health Programme, World Health Organi-sation (ICD-10, 1992), will be followed in this paper.

According to this classification two groups of symptoms are outlined. The firstgroup includes the most characteristic symptoms for schizophrenia, any of which issufficient for the diagnosis of the disease. These symptoms are:



a. Disturbance of the mechanisms of thought, such as thought echo, thoughtinsertion or withdrawal, and thought broadcasting. The patient have the feelingthat his thoughts are either echoed, withdrawn, or broadcasted, or that foreignthoughts are inserted in his mind without his own will.

b. Delusional perception, which is the belief that a given perception conveys aspecial message for him; delusions of control, influence, or passivity, clearlyreferred to body or limb movements or specific thoughts, actions, or sensations.

c. Hallucinatory voices giving a running commentary on the patient's behavior, ordiscussing the patient among themselves.

d. Persistent delutions of other kinds that are culturally inappropriate and com-pletely impossible.

The second group of symptoms is less characteristic and there is a need of thepresence of two of the symptoms during a period of 1 month or more for thediagnosis of schizophrenia to be made. These symptoms are:

e. Persistent hallucinations in any modality, without clear affective component.f. Breaks of interpolations on the train of thought, resulting in incoherence or

irrelevant speech, or neologisms.g. Catatonic behavior, such as excitement, posturing, or waxy flexibility, negativ-

ism, mutism, and stupor.h. "Negative" symptoms such as marked apathy, paucity of speech, and blunting or

incongruity of emotional responses, usually resulting in social withdrawal andlowering of social performance.

i. Loss of interest, aimlessness, idleness, a self-absorbed attitude, and social with-drawal.

The Family System

The families of schizophrenics, have certain characteristics. Here, the mostimportant results of the empirical research in the field of social psychiatry, will bepresented. On the contrary, the various theories of the different schools of familytherapy, concerning the causes and characteristics of the family system as a result ofobservation during the therapeutic process, will not be mentioned. The presenta-tion of the family characteristics will start with the presentation of the properties ofthe members of the schizophrenic family, followed by the presentation of thecharacteristics of the subsystems and the relations among the family members.

When a family has a schizophrenic member, then the probability of anothermember to be also schizophrenic is several times higher in this family than in theaverage one (Rosenthal, 1971). Alanen (1958) found that more than half of themothers of schizophrenics were psychologically or psychiatrically disturbed, anddid not respect the child as an independent person. In the parents of schizo-phrenics there is high incidence of thought disorders, paranoid behavior andattitudes or shared delusions (McConaghy, 1979; Singer and Wynne, 1965; Wenderet al., 1968). These findings are considered to be largely due to hereditary factors(Weiner, 1980).



The parents of schizophrenics have highly disturbed relationships. They showopen or tacit conflict, disagreement, opposition of spontaneously expressed atti-tudes, and difficulty in reaching agreement more than do control groups (seeHirsch and Leff, 1975).

The parents of schizophrenics apart from their deviation from the normalinternal experiences and behavior they have specific properties of contact, commu-nication and type of messages and information they offer to the other members ofthe family including the pre- and post-schizophrenic patient. Singer and Wynne(1965) found that the mode of communication between the family members of theschizophrenic family is loose, vague, discontinuous and with lack of integration.These findings confirmed later by Carter etal. (1987), Hirsch and Leff (1971) foundthat the speech of the parents of schizophrenics shows vagueness and odd associations.

Bateson observed with his colleagues that the parents of schizophrenics sentcontradictory messages to their schizophrenic children (Bateson et ai, 1956). Thisobservation was conducted without the use of control groups. However, very suc-cessful treatment methods in family therapy, for many decades, have been based onBateson's assumptions (the presence of paradoxes) which are supported by otherresearch as well (e.g., Rierdan and Brooks, 1977).

Critical comments (statements of resentment, disapproval, dislike or rejection)and emotional overinvolvement (excessive anxiety, overconcern, or overprotective-ness) expressed by a key relative found to be the best predictor of schizophrenicrelapse (Brown et al., 1972; Vaughn and Leff, 1976). The lack of these factors,termed as expressed emotions, proved to be the best protective factor againstrelapse, far better than anti-psychotic medication (Vaughn and Leff, 1976).

The Soclo-Cultural Level

There are various studies concerning the relationship between socioculturalcharacteristics and schizophrenia. Several of them are contradictory. Thus onlythose with considerable importance and empirical evidence, which are not contra-dicted by other studies, will be mentioned. The interpretation or their relevance tothe etiology of schizophrenia will be avoided.

Social isolation is one of the most important social characteristics of schizo-phrenics, and are included into the so called "negative symptoms." Sundby (1955)found that the incidence of schizophrenia is higher in the sea merchants than in thegeneral population. Faris and Dunham (1939) showed that many schizophrenicsare living in central areas of the city, were social isolation, poverty and socialdisintegration are greater. In consequent studies, the excess schizophrenic admis-sions from central areas of the city were found to be entirely due to those who hadmoved there recently (Gerard and Houston 1953).

Besides, schizophrenics belong to a lower social class than the general popula-tion, which is not due to their parents (e.g., Goldberg and Morrison, 1963). Theyare also unmarried, at higher incidence than normals, and have lower fertility (seeKendel, 1988). Schizophrenia is also higher among immigrants, exceeding the ratesof the native population (e.g., Odegaard 1932; Carpender and Brockington, 1980).



AN OUTLINE OF A MULTILEVEL MODEL OF THE IDENTITY OFSCHIZOPHRENIA

The description of schizophrenia at the various levels of systems hierarchicalorganization, offers a more complete view. In addition, the considerable increase incomplexity of a multilevel description can be reduced by making abstractions. Inparticular, by presenting the most important parts and their relations, in a way thatwould be useful for a particular purpose as it is the treatment and rehabilitation ofthe schizophrenic.

One way to achieve this is by identifying some dimensions or factors of interre-lated characteristics at several levels of systems hierarchical organization. In partic-ular, three different dimensions will be presented, which are supposed to be relatedto heredity as well.

1. There is a reduction of functioning of left hemisphere and to a lesser extent ofthe frontal lobe. Lack of inhibition between neurones encoding opposite con-cepts, statements or modalities (a hypothesis, see Paritsis, 1993). Use of ben-zodiazepines for the treatment of schizophrenia. Thought disorders and mostsymptoms (mainly the Schneiderian and that of Bleuler) of schizophrenia withthe exception of hallucinations. Contradictory messages from family environ-ment. Critical comments.

2. An excitation and dysfunction of the temporal lobe and of the limbic system.Use of antipsychotic drugs in the treatment. Hallucinations and delusions of allkinds. Hostility and critical comments in the family environment. Social stresses.

3. Atrophy and reduction of activity of the frontal lobe and to a lesser extent of thewhole cortex. Use of antidepressants for the mobilization of the schizophrenic.Primitive thinking. Negative symptoms of schizophrenia. Over-concern andover-protectiveness from family environment. Social isolation and deprivation,and environmental rejection.

The parts of above dimensions influence each other at various levels. Reductionfor example of the activity at one part of the brain may inhibit or excite anotherpart.

DISCUSSION AND CONCLUSIONS

The identity of schizophrenia is a good example for examining the usefulness ofthe description at many levels of systems hierarchical organization. The descriptionat one level has the advantage that a specialist for this particular level would be ableto fully understand this description. He will be also happy to be in a familiar field ofknowledge. He will also have the feeling that this level is of considerable importance(since a large part of his knowledge exists at this level). Such an approach is themedical approach in psychiatry. The disadvantage of this approach is that theknowledge at one level is in several cases not sufficient to solve the problem, or toinfluence considerably the involved phenomena. Also, the problem may be solved



only partially, or to an unsatisfactory degree. Since, each level exercises its owninfluence on the whole phenomenon.

In order to study a phenomenon at many levels of systems hierarchical organiza-tion, it is necessary for the scientist to have a considerable knowledge at each level.This necessitates a long term education or study on each field. A method ofovercoming it is through the collaboration of many specialists. In this case none ofthem would have the feeling that his own level of knowledge is of paramountimportance. On the contrary, each of the scientists will have the feeling that heignores more than he knows. This is the case of the biopsychosocial interdisciplin-ary approach to psychiatry.

Furthermore, in order to follow the systems approach of a multi-level description,the education or study in systems science is necessary, in addition to the specificsubject. However, this necessity can be diminished, because, through the knowledgeof systems science the scientist will need less time for his studies in systems, than forbeing specialist at many levels. In addition he will be able to better understandmany other fields with a relatively small amount of their knowledge. He will be alsoable to understand the subject through collaboration with the specialist by usingless time. Another advantage of the systems approach is that the systems scientistwill be able to make a relatively abstract model of the phenomenon that unfolds atmany levels of systems hierarchical organization. This can be done by selecting themost important variables at each level, and in particular those that have a major rolein determining the phenomenon under study; having in mind the importance ofdrawing the relations between elements at the same level, and between levels, thatwould be useful for a particular purpose. Finally, by knowing the systems principlesreferring to the content and the methodology of systems science, the scientist wouldbe in a better position to predict the behavior of the system.

In conclusion, the multilevel analysis, description and intervention at many levelsof systems hierarchical organization, as an interdisciplinary approach, has advan-tages over the analysis at one level of systems hierarchical organization. Further-more, the systems approach have advantages over the interdisciplinary approach towhich it is complementary.

This is also the case of defining the identity of schizophrenia. The analysis of theoutlined model presented in this work, in order to demonstrate its usefulness fortreating, managing, and rehabilitating schizophrenic patients, is beyond the scopeof this work. However, a previous work can be mentioned (Paritsis, 1989), accordingto which, this multilevel analysis and intervention was applied for the treatment andrehabilitation of chronic institutionalized schizophrenic patients. According to theresults, the effectiveness of the services were tripled.

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